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NOTES ON 

PHYSICAL DIAGNOSIS 



BY 

JOHN METCALFE POLK, A.B., M.D. 

LA TE 

Instructor in Medicine, Cornell University Medical College 
and Adjunct Assistant Physician, Bellevue Hospital 



EDITED BY 

C. N. B. CAMAC. A.B., M.D. 



^ 



NEW YORK 

CORNELL UNIVERSITY MEDICAL COLLEGE 

1905 






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COPY a. 



Copyright, 1905, by 
DR. WILLIAM M. POLK 



Press of J. J. Little & Co. 
Aster Place, New York 



The publication of this work is undertaken not 
merely as a memorial to its lamented Author, but 
because of its intrinsic merit in elucidating a subject 
which presents problems of exceptional difficulty to 
students of medicine. Yet one who was long and 
closely associated with Dr. Polk throughout his stu- 
dent and hospital days, as well as in his later field of 
usefulness as an instructor, may be permitted to add 
a word of tribute. His relations with his fellow- 
students, his teachers and his patients alike, were 
marked by a courtesy and unusual charm of man- 
ner, which, with his enthusiasm for scientific work 
and scholarly attainments, fitted him in special de- 
gree for professional successes, had he been longer 
spared to achieve them. 

The work has been brought fully to date by the 
editorial revision of Dr. Camac, and has received the 
unqualified approval of all the instructors in the de- 
partment which it covers. 

W. Oilman Thompson. 



INTRODUCTION 

In the spring of 1903, Dr. John Metcalfe Polk 
and I talked over the advisability of getting to- 
gether notes for the third year class in the Cornell 
University Medical College, on Physical Diagnosis,, 
which subject we, together w^ith Dr. Montgomery 
H. Sicard, had been appointed to teach during the 
ensuing winter. We met several times and com- 
pared our notes, Dr. Polk's being largely transla- 
tions from Sahli, while mine were taken chiefly from 
British and American authorities. 

The work was engaging and instructive, and I re- 
call with advantage the questions which were raised 
and which we endeavored to answer in the post- 
mortem room. I cannot let this opportunity pass 
without urging upon instructors the cultivation of 
this free discussion of doubtful signs, and the study 
of the normal post-mortem appearance while such 
questions are fresh in the mind. The benefit and 
life which it gave to our teaching was a subject of 
frequent remark between us. 

With these associations it was with peculiar inter- 
est that I received the manuscript of these notes 
from Dr. Wm. M. Polk and with affectionate regard 
for his son I set about placing in enduring form 
this one of the many evidences of that thoroughness 
which characterized all the undertakings of our col- 



IXTRODUCTIOX 

league, whose gentle and considerate ways were all 
too soon taken from among us. 

While Sahli is the authority for many of the state- 
ments made, the notes are by no means a mere trans- 
lation. With the exception of a few final revisions, 
changes of sequence of various subjects, the notes 
are exclusively the work of Dr. Polk. W^here ad- 
ditions have been made they are indicated as foot- 
notes. 

I am indebted to Dr. Walter L. Niles for re-read- 
ing the proof. 

C. N. B. Camac. 



CONTENTS 

PAGE 

I. GENERAL EXAMINATION 9 

Inspection 9 

Mensuration 12 

Percussion 12 

Palpation . . . 16 

Auscultation 18 

Of breath sounds 18 

Rales 21 

Of voice sounds 22 

II. DETAIL CONSIDERATION OF METHODS 

OF PHYSICAL EXAMINATION . . 25 

The Thorax 25 

Inspection, normal Thorax 25 

" abnormal Thorax . . . . 25 

- Respiration, normal 29 

" abnormal; dyspnoea . . .32 

Lungs and Pleurae 41 

Palpation 41 

Percussion 43 

Comparative Percussion 52 

Auscultation 57 

Heart, Pericardium and Vascular Sys- 
tem 70 

Inspection and Palpation 70 

Percussion 75 

Auscultation 80 

Pulse and Arterial Wall 100 

III. DIFFERENTIAL DIAGNOSIS .... 108 

IV. DISEASES OF PLEURA AND LUNGS .121 



It is hardly an exaggeration to say that [honest work is never thrown 
away. If we do not find the imaginary treasure, at any rate we enrich 
the vineyard. 

John Lubbock. 



GENERAL EXAMINATION 

The application of Physical Diagnosis is furthered by 
an outline plan which is comprehensive enough to cover 
the topographical peculiarities and variations of the field, 
whether they be on the surface or beneath; and specific 
enough to indicate to the examiner any one of its methods 
he may need in the solution of his problem. Such an out- 
line, however, should be sufficiently concise to be readily 
held in memory. 

Attention, therefore, is first asked to the following con- 
densed statement of subject and matter which is to be 
elaborated as we progress in our course. (See page 25.) 



INSPECTION: 

Position of Patient: 

Standing, 

Sitting, 

Lying. 

The body and the extremities must be straight and 
the muscles relaxed. 
Light : 

Direct, 

Oblique. 
Condition of Abdomen : 

Normal, 

Relaxed, 

Distended, Generally, 
Locally. 
Bony Deformities : 

Fractured Clavicles, etc., 



lo NOTES ON PHYSICAL DIAGNOSIS 

Spinal Curvatures, 
Deformed Pelvis, 
Shortened Leg. 
Bony Landmarks: 

Supra Sternal Notch, 

Clavicles, 

First Interspace, 

Junction of Second Rib with Sternum, 

Base of Xyphoid Cartilage, 

Seventh Rib at Sternum, 

Eleventh and Twelfth Ribs, 

Seventh Cervical Spine, 

Fourth and Twelfth Dorsal Spines. 

Surface Markings : 
Mid-sternal Line, 
Sternal Line, 
Parasternal Line, 
Mammary Line, 
Anterior-axillary Line, 
Mid-axillary Line, 
Posterior-axillary Line, 
Scapular Line, 
Spinal or Mid-dorsal Line. 

Outline of the Lungs : 

One inch above inner third of clavicle anteriorly, 
Eleventh cervical spine posteriorly. 
Right Lung: Sternal 6th rib, 

Mammary 6th rib, 
Mid-axillary 8th rib. 
Scapular loth rib, 
Spinal nth rib, 
Left Lung: Sternal 4th rib, 

Parasternal 5-6th rib. 
Mammary 6th rib, 
Mid-axillary 8th rib, 



GENERAL EXAMINATION ii 

Scapula loth rib, 
Spine nth rib. 
Division of Lobes : 

Left: Begins at 4th Dorsal Spine, 
Mid-axillary 5th rib, 
Parasternal 6th rib. • 
Right : Begins at 4th Dorsal Spine, 
Divides at middle of Axilla, 
Upper goes to Sternal line at 4th rib. 
Lower to Mammary line and 6th rib. 
Tracheal Bifurcation is opposite the 4th dorsal spine 
posteriorly and the 3d costal cartilage anteriorly. 
Size and Shape of Thorax : 
Normal, 
Phthisical, 

Emphysematous J ^, '. 
) Chronic, 

Rachitic, 

Harrison's Groove, 
Pigeon Breast, 
Costo- Sternal Groove, 
Kypho-Scoliotic, 

Congenital, 
Funnel Shaped, 

Acquired (Boat shaped). 

BULGINGS : 

Diminished Expansion, )...,, , ^ , 
-r, ^ . . V L nilateral or Local. 

Retractions. j 

Types of Respiration : 
i Costal, 
Normal -l Costo-Abdominal, 

( Abdominal, 
Pathological. 
Diaphragmatic Excursion : 
Litten's Sign, 



12 NOTES ON PHYSICAL DIAGNOSIS 

Unilateral Diminution, 
Absence of Movement, 
Inspiratory Abdominal Insinking. 

Dyspnoea : 

Catchy, 

Accelerated, Superficial, 

Slow, Deep, 

Inspiratory Dyspnoea, 

Expiratory Dyspnoea, 

Irregular, 

Cheyne-Stokes. 
Abnormal Movements of the Thorax : 

Emphysematous, lack of lateral expansion, 

Normal insinking of lower interspaces, 

Abnormal sinking of ribs and interspaces. 

MENSURATION : 

Circumference, 
Semicircumference. 
Cyrtometry : 
Diameters. 
Shape of chest at various levels. 

PERCUSSION : 

Methods: Immediate; Finger, 
Fingers. 
Mediate: Fingers, 

Instrumental, 
Auscultatory Percussion: Stethoscope on 
organ, percuss or scratch toward stetho- 
scope. 

Stethoscope as centre, percussion in 
circle. 
Coin clink in pneumothorax. 
Tactile Percussion: 



GENERAL EXAMINATION 13 

Attributes of Percussion : 
Vesicular. 

( Flat or hard, 
^ ^1 Tympanitic. 

Duration J J^^^' 
) Short. 

Intensity | ^^^^^ 

Pitch i fS"^' 

[ Low. 

Five Types of Percussion Note Obtained over 
Thorax : 

Flat or Hard, 

Dull, 

Vesicular or Resonant (Normal), 

Hyperresonant or Vesiculo^tympanitic, 

Tympanitic. 

Attributes of the Five Types : 

Flat : Quality Hard, 

Duration Short, 

Intensity Diminished, 

Pitch High. 

Dull : QuaHty Hard Vesicular, 

Duration Decreased, 

Intensity Slightly Diminished, 

Pitch Higher than Normal. 

Vesicular : Quality Vesicular, 

Duration Long, 

Intensity Loud, 

Pitch Low. 

Hyperresonant : Quality Vesiculo-Tympanitic, 

Duration .... Long or Short, 
' Intensity .... Loud, 

Pitch Low or High. 



14 NOTES ON PHYSICAL DIAGNOSIS 

Tympany : Quality Musical, 

Duration Short or Long, 

Intensity Decreased or Loud, 

Pitch High or Low. 

Rules for Percussion : 

Position of patient ; perfectly upright or flat, muscles 
relaxed. 

Compare corresponding points on both sides of chest. 

Comparison should be made in same stages of res- 
piration. 

Finger should be applied with equal firmness and in 
the same parallel on both sides. 

Strike with equal force on both sides. 

Have listening ear at the same distance from points 
percussed. 

Conditions Influencing the Percussion Note in the 
Normal : 

Position of patient, 

Muscular contractions, 

Bony structures. 

Muscle, fat, oedema, 

Thoracic and spinal deformities. 

Structure of organs within the thorax and abdomen, 

Respiratory phases. 

Variation in the Percussion Note of the Normal 
Thorax : 

Above and below the clavicles pure vesicular; right 
higher pitched than left, 

Over the pectorals the note is slightly dull depend- 
ing on the thickness of the muscle or gland, 

Sternum, to third rib vesiculo-tympanitic due to 
trachea, 3d to 4th rib vesicular, 4th to 6th rib dulness 
of heart. 



GENERAL EXAMINATION 15 

Sternal Lines : 

Right : 3d and 4th ribs, relative dulness of heart, 
5th rib, relative dulness of liver, 
6th rib, liver flatness. 
Left : 3d interspace, relative heart dulness, 
4th to 6th interspace, cardiac flatness, 
6th interspace, liver flatness extending to the 
left as far as the parasternal line. 
Right ^lammary Line: 5th interspace, relative liver 

dulness, 
6th interspace, flatness of 
liver. 
Mid-axillary Lines : 

Left: Good resonance and note increasing in fifll- 
ness as one descends, due to stomach, till splenic dul- 
ness is reached at about the 9th rib and extends to the 
nth rib. 

Right: Good resonance till relative dulness of 
liver is reached at 8th rib, flatness at 9th rib. 
Posteriorly (Scapular Line) : 

Note high pitched above due to the muscles and 
bones; on the right, relative liver dulness at 9th, ab- 
solute at loth; on left, flatness of muscles at loth or 
tympany of stomach or colon. 
Pulmonary Excursions : 

The lung moves normally in respiration about an 
inch; on deep respiration about 2f to 3 inches. 

Other Abnormal Percussion Notes and Signs: 

Amphoric resonance: this is similar to striking the 
cheek when the mouth is filled with air. Is heard over 
cavities. 

Cracked Pot: is similar to striking the closed hands 
on the knee; is a stenotic murmur due to air being 
driven from a cavity through a narrow opening. Ob- 



i6 NOTES ON PHYSICAL DIAGNOSIS 

tained in the normal chest by percussing thin walled 
elastic thorax while the patient speaks, or in children 
when crying. 

Obtained over cavities under the following condi- 
tions : 

The cavity must be over 6 mm. in diameter. 

It must be superficially situated. 

Must have elastic walls and open into a bronchus. 

Wintrich's change of note : On percussion over a 
cavity a higher pitched tympany is obtained when the 
patient's mouth is open than when it is closed. This 
observation must be made under the same phase of 
respiration. 

Gerhardt's change of note: is found in oval cavities 
half filled with fluid. Percussion over the short diam- 
eter gives a lower note than over the long. This 
should be made with the patient in several positions. 

Biermer's change of note in pneumothorax : There 
is a higher pitched note in the lying position than in 
the standing, the cavity being enlarged in the latter 
position by the descent of the diaphragm. 

Williams' tracheal note (tympany) : obtained over 
consolidations near large bronchi or over the aj>ex in 
complete compression of the lung in pleurisy. 

Friedrich's sign: a high pitched note over a cavity 
on inspiration and a low pitched one on expiration. 
This is also obtained over the normal lung. 
PALPATION: 

The position of the patient should be the same as in 
percussion. 

Examine for areas and points of tenderness, as 
Over pleurisy. 

Over seat of intercostal neuralgia. 
Over praecordium in heart disease (not con- 
stant), and 



GENERAL EXAMINATION i? 

For resistance and fluctuations. 

For variations and degrees of local expansion. 

For tactile or vocal fremitus. 

Fremitus : 

A vibration produced in the larynx is transmitted 
down the columns of air in the bronchi to the lung 
tissue and thence to the chest wall and hand. 

Note. — The terms Vocal and Tactile, as applied to fremitus, refer to 
the sensation conveyed to the liand (tactile) by the vibration of the voice 
(vocal). (See also note on page 41.) — Editor. 

Rules: Compare corresponding points on each side 
of the chest. 

Apply both hands. 
Apply one hand. 

Conditions Varying the Fremitus in the Normal 
Chest : 
Fremitus is more marked in : 
The adult than the child. 
Men than women. 

Thin people than in fat or muscular. 
Deep voiced than in high. 
Strong people than in weak or sick. 
Conditions of the larynx. 
The words selected, 99 being better than 66. 
Diminishes in intensity the further one goes from 
the large bronchi ; is most marked : 

Over the upper part of the sternum. 
Between the scapulae at the fourth cervical ver- 
tebra. 

Over apices. 

The vocal fremitus is more marked over the right 
apex both anteriorly and posteriorly and in the right 
axilla than on the left side. 

Three theories for this difference : 



1 8 NOTES ON PHYSICAL DIAGNOSIS 

The right bronchus is given off higher up and at 
more of a right angle and is larger than the left. 

The liver may influence the fremitus. 

The right thorax is larger by one-half an inch than 
the left. 

Tussile fremitus : is a vibration felt on coughing. 

Rhonchial fremitus : is a vibration produced by 
moist rales. 

Friction fremitus : is a vibration produced by pleuri- 
tic or pericardial rales or rubs. 

AUSCULTATION : 

Mediate with stethoscope. This is to be used only 
when locating fine superficial rales. Distant tubular 
breathing cannot be heard with the stethoscope. 

Ear. With or without sounding cloth. 

Rules : 

The position of the patient is the same as for per- 
cussion. 

The position of the examiner should be comfortable 
and the head not too low. 

Auscultate with normal rate and depth of respira- 
tion. 

Auscultate with forced respiration. 

Auscultate after the patient has coughed, and dur- 
ing cough. 

Always listen at the patient's mouth to catch the 
character of the sound there produced. 

Breath Sounds or Respiratory Murmurs: 

Inspiration is a muscular act. 

Expiration is (largely) a passive elastic retraction of 
the thoracic walls and lungs. 

Any condition altering this elasticity causes mus- 
cular effort in expiration. 



GENERAL EXAMINATION 19 

The duration of the inspiratory act is physiologically 
shorter than that of the expiratory. 

Note. — On listening over the normal chest, however, inspiration is 
audible for a longer period than is expiration. — Editor. 

The normal respiratory murmur is produced in the 
larynx. The vibration passes down the column of air 
and the bronchial wall and is diffused through the al- 
veolar spaces and the soft lung tissue to the chest wall 
where the auscultating ear appreciates the murmur as 
a soft rustling sound. 

The normal inspiratory murmur is heard throughout 
the inspiratory phase. Then follows a slight pause. 
Then the expiratory murmur which may vary in dura- 
tion from one-half the length of the inspiration to none 
at all. 

Causes : Inspiration is a muscular act ; expiration 
partially muscular but largely passive. 
The current of air on inspiration is passing 
toward the auscultator, and away from 
him on expiration. 

The Attributes of Respiration : 

Rhythm, 

Intensity, 

Pitch, 

Duration, 

Quality. 
Alteration in the Rhythm : 

Interrupted, 

Prolongation of pauses, 

Expiration prolonged. 

Alterations in Intensity: 
Absent breathing, 
Decreased, 
Increased or exaggerated. 



20 NOTES OX PHYSICAL DIAGNOSIS 

Alterations in Quality: 
Harsh or rude, 
Broncho-vesicular : 
Inspiratory, 
Expiratory, 
Mixed. 
Puerile, 

Bronchial or tubular, 
Cavernous, 
Amphoric. 

All of the latter except the puerile are accompanied 
by a prolongation of expiration and are increased in 
intensity (may be decreased). 

Puerile breathing has the broncho-vesicular quality, 
but is normal in rhythm. 

The Variations in the Breath Sounds in the Nor- 
mal Chest : 

The normal vesicular murmur is heard under the 
left clavicle and below the angles of the scapulae. 

(a) Women louder under clavicle (costal breath- 
ing). 

(b) Men louder under scapulae (diaphragmatic 
breathing). 

Harsh prolonged expiration under the right clavicle 
and at the posterior right apex. (See causes of variai- 
tion in fremitus, page 17.) 

Bronchial, upper part of sternum. 
Harsh, at fourth dorsal due to bifurcation of trachea. 
All these signs vary in different persons. 
The Pathology and Physics of the Alterations in 
THE Breath Sounds : 

Absence of the murmur is due to : 
Lack of expansion of lung, 
Obstruction of a bronchus. 



GENERAL EXAMINATION 21 

Separation of the lung from the thorax. 

Diminished murmur is due to : 

Rigid hmg from inflammation, 
Diminished expansion from adhesions, 
Dilatation of air sacks in emphysema. 

Harsh or rude breath sounds are due to : 
Bronchitis, 
Early infiltrations. 

Broncho-vesicular sounds are due to : 

Areas of consolidation mixed with normal lung 

tissue. 

Bronchial: Hig^h pitched ") ^^ ,. 

,^ ,. Dependmp; upon the ex- 

Medmm V ^ ^ , ^, ^ ... ^. 

^ ( tent of the consolidation. 

Cavernous ) „ . . 
, , . V Cavities. 
Amphoric i 

Rales : 

Note. — These are never heard over the normal lung except at the 
lower axillae and under the clavicles of shallow breathers. In such indi- 
viduals a shower of crepitant rales is heard at the end of the first or 
second deep inspiration and then they are not again heard. The differ- 
ential feature between these normal rales and those due to pathological 
causes is that the latter are constant. — Editor. 

Pleuritic Friction Rales: are heard during inspira- 
tion and expiration close to the ear and are not 
changed by coughing. 
Moist : 

Crepitant. 

Crepitant Rales : are heard usually in showers at 
the end of inspiration but may come at any time during 
inspiration and expiration, are produced in the alveoli, 
and are heard in all early exudative inflammations of 
the alveoli, in atelectasis and pleurisy. They are the 
finest and most clear cut and crackling rale that is 
heard. They decrease in number after a time but do 



2 2 NOTES ON PHYSICAL DIAGNOSIS 

not change their character or location after deep 
breathing and coughing. 

Fine Mucous or Bronchial Subcrepitant Rales: are 
produced by mucus in the finest bronchioles, are moist 
in character, distant from the ear and change in char- 
acter, number and position on coughing. 

Medium and Large Mucoiis Rales: are produced by 
mucus in bronchi of various sizes. 

Mucous Gurgles: large and small; are heard over 
cavities. 

Dry: 

New leather rub. 

Dry subcrepitant. 

Sibilant Rale: is a whistle due to stenosis of the 
small bronchi. 

Sonorous Rale: is a musical vibration in the large 
tubes due to stenosis. 

Mucous Click: is a clicking sound not disturbed by 
coughing. 

SuccussiON : 

Is a splashing sound obtained by shaking the pa- 
tient's thorax from side to side. Is heard in large cav- 
ities and in pneumothorax with fluid. 
The Effect of Cough ox Rales : 

It brings them out when absent without it. 

It intensifies existing rales. 

It obliterates rales by clearing the bronchi of mucus. 

Auscultation of Voice: 

Follow^s the same general laws as vocal fremitus and 
is increased or diminished over the normal chest as is 
fremitus. 

The sound heard is that produced in the larynx and 



GENERAL EXAMINATION 23 

is transmitted by the air in the air passages and by the 
lung tissue and thoracic wall to the listening ear. The 
word itself, as a rule, cannot be recognized. 

Over larynx: Laryngophony. 

Over upper sternum : Bronchophony. 

Over lung substance : Normal vocal resonance. 

This last has none of the characteristics of an artic- 
ulated word. 

Vocal resonance may be : 
Absent, 
Decreased, 
Normal, 

Increased or exaggerated, 
Changed in character or quality. 
Under the latter we have : 

Bronchophony, which approaches an articulation, is 
higher pitched and more intense than the normal vocal 
resonance, having a peculiar vibratory quality. Is 
heard in early infiltrations before tubular breathing is 
to be heard. 

Pectoriloquy : is a clear transmission of the voice, 
the spoken word being heard distinctly. It differs from 
bronchophony in that it is a transmission of speech 
while the first is a transmission of sound only. Is 
heard over consolidations and cavities. 

Aegophony: is a resonance of a tremulous, nasal 
character (similar to the bleating of a goat) ; it is rarely 
heard and is not characteristic. It is heard at the angle 
of the scapulae in slight pleural accumulations with 
compression of the lung. 

Note. — Remembering that pho7ios means sound and loqiior means 
speech, the significance of these terms will be appreciated. Thus we 
have bronchophony meaning bronchial sound — words not distinguishable, 
and pectoriloquy meaning chest speech, words clearly heard. These 
terms were originally employed by Laennec, the great French Clinician 
%nd inventor of the Stethoscope. — Editor. 



24 NOTES ON PHYSICAL DIAGNOSIS 

Cavernous- voice: is a hollow deep tone. 

Amphoric voice: is a resonance of a hollow metallic 
character with a musical quality. It is heard over 
large cavities and in pneumothorax. 

Whispered voice: It may be employed in place of 
the respiratory sound in those too weak to take a deep 
breath. Normally it is heard over the upper part of 
the chest near the large bronchi. 

Note. — In thin-chested individuals a modified whispered voice may 
be heard all over the chest. — Edito)-. 

Exaggerated bronchial whisper. 

Whispered bronchophony. 

Whispered pectoriloquy. 

Cavernous whisper. 

Amphoric whisper. 

These names apply to the same variations in the 
character and quality of the whisper as is heard in the 
case of the voice. The variations are found under the 
same pathological conditions as those of the voice, but 
when obtained are more pathognomonic of the condi- 
tions. 

The metallic tinkle : Is a sound similar to water being 
dropped into a metallic vessel. Is heard during the 
respiratory phases over large cavities and in pneumo- 
thorax. 

The resonance of cough: 

Bronchial Cough, 

Cavernous Cough, 

Amphoric Cough. 

Note. — Metallic laryngeal cough, ringing or brassy in character.— 
Editor. 



DETAIL CONSIDERATION OF METH- 
ODS OF PHYSICAL EXAMINATION 

THE THORAX 

i 

The Normal Thorax. 

Inspection: Epigastric or costal angle should be 
about a right angle; convexity of the ribs should 
be gradual and uniform, with no angles of prom- 
inence; lower interspaces should be apparent, the 
upper ones should not be apparent ; antero posterior 
diameters should be less than the transverse; the 
horizontal measurements should increase slightly 
from above downwards. 

Sternum: Straight, and without prominences or 
depressions, except a shght prominence at the junc- 
tion of the manubrium with the gladiolus, which 
marks sternal position of the second rib. 

Scapula:: Should lie flat and not sink too low; 
foss9e should not be too deep. 

The Abnormal Thorax. 

Emphysematous, Acute: In fhe acute stages there 
is a retraction of the lower and bulging of the upper 
portion of chest, with a consequent diminished tho- 
racic capacity. Chronic: The thorax is enlarged; 

25 



26 NOTES ON PHYSICAL DIAGNOSIS 

abnormally bulging, antero posterior diameter equal 
or greater than transverse; epigastric or costal angle 
is obtuse; spine curved. If the emphysema is diffuse, 
or confined to the lower parts of lungs, the chest 
assumes the position of normal inspiration. If the 
emphysema is old or of long standing, there is much 
cough and the upper part of the thorax is dilated, 
the lower part being contracted. In general emphy- 
sema the thorax assumes the shape which constitutes 
the true " Barrel Shaped Chest.'' 

The Paralytic or Phthisical: A flat, long, narrow 
thorax ; ribs in front and behind are abnormally slant- 
ing; the epigastric or costal angle acute, intercostal 
spaces broad, fossae deep, due to the relaxation and 
weakness of the muscles ; the shoulders droop and 
the scapulae flare out widely. This thorax is seen 
also in weak people, and is a predisposing cause to 
tuberculosis, with which disease it is usually asso- 
ciated. 

The Rachitic Types: Transversely constricted. In 
this type the Harrison's grooves are seen. These 
begin at the xyphoid cartilage, and pass to the mid- 
axillary line. These are seen in children and are pro- 
duced by the obstruction to the entrance of air as by 
adenoids, etc. The result is that the upper part of the 
chest is expanded by the muscular effort, the middle 
part forced in by atmospheric pressure and the costal 
borders are flared out widely by the distended abdo- 
men. 

Pigeon Breast: A groove runs from above down- 
wards on either side of the sternum, and the antero- 
posterior diameter is increased with a narrowing of 



METHODS OF PHYSICAL EXAMINATION 27 

the lateral diameters. The " Rosary " may be present. 

All these rachitic forms may be combined, and as 
the child advances in years the deformity may dimin- 
ish or entirely disappear. 

The Boat Shaped Breast: This is a marked depres- 
sion of the upper portion of the chest, and is due to an 
atrophy of the pectoral muscles. It is an apparent 
malformation only of the bony structures, as there is 
no actual variation in bone formation. 

Note. — This type is rare and is usually confused with the follow- 
ing. — Editor. 

The Funnel Breast (the congenital or true) : In this 
the sternum wholly from above downwards takes a 
slant inwards. In this form of chest the organs may 
be compressed, giving the same results as in scoHo- 
kyphosis. Acquired or false. In this only the lower 
portion of the sternum near the xyphoid alone sinks 
in. There is no interference with the chest activity. 

This depression, like that of the Harrison's Grooves, is due to the 
pull of the diaphragm, but at its sternal attachment, and indicates un- 
usual efforts at inspiration such as would be exercised by a child over- 
coming chronic obstruction in the air passages, as adenoids or hyper- 
trophied post-nasal mucosa. In early childhood the bony structures 
yield and a tendency to funnel breast would prompt the clinician to 
examine the throat and posterior nares. — Editor. 

The Kypho-scoliotic : Variations in the shape of the 
chest during hfe : 

Cylindrical at birth. 
Oval after the first year. 
Norma] of adult. 
Oval in old age. 



28 NOTES ON PHYSICAL DIAGNOSIS 

The Asymmetrical Thorax: An enlargement of one- 
half of the thorax is due to disease; as in pleural 
exudates, pneumo-thorax and pulmonary infiltra- 
tions; in these the enlarged side is broader than the 
uninvolved, the mammae and shoulder plates are 
further from the median line and the shoulder is 
higher. In cases of large exudates the spine is 
curved towards the involved side in order that the 
body may maintain its equilibrium. 

Large Spleen, Large Liver, Local Tiiinors of the Ab- 
domen may bulge the lower portions of the thorax, 
especially when prevented from sinking by adhesions. 
Meteorism and Ascites; the lower portion of thorax 
may be markedly bulged by accumulations of fluid or 
gas, the costal borders flare outward, greatly increas- 
ing the lower diameters of the thorax. This is espe- 
cially to be borne in mind with reference to the action 
of the diaphragm. 

Local bulging due to Tumors, Aneurysms, Enlarged 
Heart, Local Pleural Accumnlations: It must be re- 
membered that anything that diminishes the negative 
pressure in the pleural sac or increases the volume of 
the lung itself will cause that side to bulge; in other 
words the intra-thoracic pressure is brought closer 
to that of the atmosphere. 

Contracting processes of the lung or pleura or com- 
binations of the two, or where a pleural exudate has 
been absorbed and the lungs have been unable to ex- 
pand to their normal volume, the thoracic walls sink 
in to meet the lungs. 

In unilateral contractions of thorax the breadth is 
narrow, shoulder sinks, mammae and scapulae are 



METHODS OF PHYSICAL EXAMINATION 29 

nearer the middle line, and the spine is concave 
toward diseased side. 

Depression of one fossa or diminished bulging on 
coughing is very suspicious of tubercular involve- 
ment. In making unilateral measurements of chests, 
take the median Hue from the pubcs to the chin, as 
the sternum is displaced markedly in all these condi- 
tions ; inspection and palpation will reveal more than 
all the measuring one can do. 

Inter-costal Bulging in Pleurisy with Effusion: The 
ribs in inspiration in their ascent may simulate a re- 
traction of the interspaces. Retraction of the lower 
interspaces on forced inspiration in thin individuals 
must not be mistaken for a sign of adherent pleura. 

Note. — Bulging of the interspaces is an extremely rare sign of 
pleural effusion. — Editor. 

In inspiration the shape of the chest and curve of 
the spine is most essential ; also the conditions of the 
abdomen, and any superficial examination of the 
abdomen for tumors, organs, gas, etc., is absolutely 
necessary for a comprehensive examination of the 
chest. 

Respiration. 

In the normal newborn is 44 to the minute, at 
5 years of age 26 to the minute, in the adult 16-24 
to the minute. There is one respiration to four 
pulse beats. Respiration increases on changing 
from the standing to the prone position, diminishes 
in sleep, is increased by exercise ; after a full meal by 
pressure on the diaphragm, by skin excitations (cold 
bath, etc.), by psychical influences; during digestion. 



30 NOTES ON PHYSICAL DIAGNOSIS 

by smoking, drinking, etc.; by temperature as seen 
in fever, and also by artificial heat. 

Forms of Respiration, Normal: Costal in women, 
costo-abdominal in men, costal (chiefly) in children. 
Pathological: limitation of excursion of diaphragm, as 
by paralysis of diaphragm, in emphysema, by pain, 
by muscular degeneration, by infections and anemias, 
by progressive muscular atrophy, by multiple neuri- 
tis, in the feeble by inflammatory conditions, such 
as pleurisy, pericarditis, subphrenic abscess, etc., the 
latter being produced partly by the pain and partly 
by the paresis, and partly by the inflammatory and 
circulatory disturbances. Diaphragmatic excursion 
is also limited by a pendulous abdomen, gravid 
uterus, large liver and spleen, gas, ascites, tumors, in 
all of which conditions costal breathing may actually 
or relatively be increased. 

Limitations of Costal Breathing: Calcification of 
ribs, of the costal cartilages, of the costal ligaments, 
of attachment of the spinal vertebrae, as in arthritis 
deformans, fractures of the ribs, degenerations and 
paralysis of the intercostal muscles. 

Litten's Sign, or the Diaphragmatic Phenomenon: 
In certain patients, by no means all, a shadowy line can 
be seen, by proper light, to descend on inspiration 
for from one to two or even three interspaces (de- 
pending on the depth of the inspiration) in the an- 
terior axillary line and to rise on expiration. It is 
caused by the diaphragm peeling from the ribs, the 
lung being slightly delayed in entering the comple- 
mental space; therefore, between diaphragm and 
edge of lung there is a line of diminished pressure al- 



METHODS OF PHYSICAL EXAMINATION 31 

most tending toward a vacuum, which causes a sUght 
sinking in of the soft parts of the thorax. It is not 
seen in very stout people or in oedematous conditions, 
pleural exudates, emphysema, adherent lung, pneu- 
monia, pneumothorax, paralysis of the diaphragm. 

Note. — If absent on one side while present on the other it is con- 
sidered as one of the early signs of tubercular involvement of the lung 
on that side on which it is absent. — Editor. 

If present it indicates that the diaphragm lies on the 
thoracic wall, and that it is movable and non-adherent. 
The sign is said to be present in subphrenic abscess 
and absent in empysema ; the accuracy of this state- 
ment is doubtful. The sign may be confused with 
the expiratory shadow produced by a sinking of the 
ribs and by the inspiratory sinking of the lower ribs, 
due to the positive abdominal pressure being substi- 
tuted for a negative thoracic pressure. In this latter 
case the wave is seen both in inspiration and expira- 
tion, whereas Litten's sign is more especially an in- 
spiratory phenomenon. 

Asymmetrical Breathing: Pathological inspiratory 
sinking of thorax, diminished or absent respiratory 
movements, can be seen in the distended as well as in 
the contracted thoracic half. Stenosis of Bronchus, 
Infiltrations, scar tissue, adhesions, hypertrophied 
heart, pericarditis (on left side only), pleural adhe- 
sions, pneumothorax, pain, are all factors. 

Peri-pneumonic insinking of the thorax is seen in 
broncho-pneumonia and atelectasis. This is due to 
the great intrathoracic pressure produced by the dia- 
phragm descending and the solidified lung failing to 
fill the complemental space, also by the direct pull of 



32 NOTES ON PHYSICAL DIAGNOSIS 

the diaphragm on the lower ribs. This is especially 
observable in children with broncho-pneumonia. In 
the same way the epigastrium and jugular fossae are 
drawn inwards. 

Abnormal Rhythm and Frequency in Respiration: 
Changes in frequency are due to dyspnoea (increased 
demand for air), as seen in exercise, deficient ven- 
tilation, etc. From nervous affections, as hysteria, 
psychoses, cerebral pressure, uraemia and diabetic 
coma. The rhythm is also disturbed in severe infec- 
tions, by increased body temperature, in the death 
agony, and by cardiac and respiratory diseases. 

The characteristic of the respiration in meningitis 
is the regularity or irregularity of the pauses, which 
are of unequal duration. This is not Cheyne-Stokes 
breathing. Cheyne-Stokes breathing has a long 
pause, followed by quick breaths, increased in 
length to a maximum, then gradually declining again 
to the pause. Cheyne-Stokes breathing is seen in 
affections of the brain, in respiratory and circulatory 
diseases, in arterio sclerosis, and in uraemia especially. 
During the pauses in this type of breathing there are 
marked changes in the pulse frequency, in the pupils 
and blood pressure, none of which, however, is con- 
stant. During the period of deepest breathing the 
patient may be cyanotic, the cyanosis increasing to 
the pause. An attack of Cheyne-Stokes breathing 
may come on during sleep. In cardiac and nephritic 
cases it may be present for months before the patient 
realizes he has any disease. Morphine increases and 
aggravates the condition. The cause of Cheyne- 
Stokes respiration is an increased excitability of the 



METHODS OF PHYSICAL EXAMIXATION 2>3 

respiratory centre, due to poor aeration of the blood. 
The blood becomes saturated with COo, which stimu- 
lates the respiratory centre, causing increased breath- 
ing till this saturation is slightly offset by oxygen. 
When this takes place breathing diminishes and the 
pause ensues. 

Dyspnoea: Objective. Increase in frequency, in- 
crease in depth (faster than normal, slower than nor- 
mal, or normal). Subjective. Increased, normal, de- 
creased, both in frequency and depth. In true 
dyspnoea the two go together with or without C3^ano- 
sis; there may be all variations of the rhythm. A 
patient may not complain of shortness of breath, but 
present a subjective dyspnoea in the objective sign of 
deep sighs. Obstructive dyspnoea with cyanosis may, 
from the CO2, so anesthetize the patient that the 
dyspnoea is uncomplained of. With praecordial dis- 
tress subjective dyspnoea is very marked, but there is 
an absence of objective dyspnoea. Marked objective 
dyspnoea may be present without cyanosis if the in- 
creased effort is sufficient to aerate the blood. Under 
this condition there is no subjective dyspnoea, and ob- 
jective dyspnoea and cyanosis are the two important 
factors. In considering the respiration, both the fre- 
quency and the depth of the respiratory movements 
must be observed. 

Forms of Dyspnoea: i. Pain necessitates the taking 
of short, rapid respirations, in order that the excur- 
sion of lung may be as small as possible. This is 
purely objective, and may be considered as a func- 
tional obstruction, the patient being compelled to 
breathe more frequently in order to make up for the 
3 



34 NOTES ON PHYSICAL DIAGNOSIS 

lack of depth. Causes : Affections of the intercostal 
muscles, rheumatism, trichinosis, fracture of the ribs, 
diseased conditions of the lung or pleura, peritonitis 
with abdominal pain. 2. Diminution of functional 
surface of lung, or mechanical limitations of lung 
movements. In this form, as a rule, respiration is in- 
creased both in depth and in frequency. There being- 
no objective symptoms and no cyanosis, as the in- 
crease is sufficient to compensate, but as soon as extra 
work is required, then subjective dyspnoea and cyano- 
sis ensue, which is particularly characteristic of early 
emphysema and brown induration, due to cardiac dis- 
eases. In pleurisy or pneumo-thorax, where one side 
of the lung is rendered entirely functionless, the 
number of respirations may be normal, but the lung 
excursions greater; this is caused by disease of the 
lung tissue, exudates in the thorax, tumors, air, dim- 
inished space in the pleural cavity, kypho-scohosis, 
upward pressure of diaphragm, diminished movement 
of lung, miliary tuberculosis, brown induration, em- 
physemia, indurated pneumonia, adherent pleura, 
paralysis and cramps of the respiratory muscles, 
dyspnoea following circulatory disturbances, and non- 
compensating cardiac lesions. The essential feature 
of all these conditions is the stasis. By the slowing 
of the circulation of the blood and the accumulation 
of the blood in the veins the venous blood loses its 
oxygen, and takes up more CO2, the respiratory 
centre thereby being excited and causing an increase 
in the number and depth of the respirations. The 
capillaries of the alveoli of the lung are not decreased 
but increased by the distended blood vessels, the lung 



METHODS OF PHYSICAL EXAMINATION 35 

being stiffer, however, and therefore less elastic. It 
is also enlarged and approaches the inspiratory posi- 
tion, causing diminution in the excursions by the lung. 
In brown induration there is an increased production 
of connective tissue, which adds both stiffness and 
increased size to the lung. Sudden accumulations of 
blood in the lung, in either acute or chronic condi- 
tions (exercise, cardiac weakness), produces attacks 
of what is called cardiac asthma. In mitral disease, 
even with compensation, cyanosis may be present 
without any subjective or objective dyspnoea, due to 
the accumulation of blood above referred to. Bron- 
chial catarrh is present in all forms of mitral disease 
and it aggravates greatly the attacks of dyspnoea 
and the general cyanosis. 

Stenosis of the Upper Air Passages: From this 
cause the respiratory activity is increased in energy, 
duration and frequency. By the increased duration 
the air can be better drawn over obstructions, and to 
compensate for this slowing of the respirations the in- 
spirations must be deeper. As the stenosis increases 
the celerity increases to a certain point, death en- 
suing from the failure of the shallow, quick breathing 
to overcome the obstruction. Causes: Large tonsils, 
retro-pharyngeal abscess, true or false croup, spasm 
or oedema of the glottis, paralysis of the vocal cord 
adductors, stenosis of the larynx and trachea, and 
a foreign body compressing the trachea. If steno- 
sis of one of the chief bronchi exists, the breathing 
will be slow and deep as long as the stenosis is over- 
come. If the stenosis is complete, the whole work 
will then be thrown on the patent lung, in which case 



36 NOTES ON PHYSICAL DIAGNOSIS 

the rapid breathing will be greatly increased. When 
the stenosis is high in the respiratory passage and of 
severe grade the lungs will not be completely filled 
with air, which will cause an increased negative pres- 
sure in the thorax, as shown by the sinking in of the 
lower lateral ribs, epigastrium and supra clavicular 
fossae. This sinking of ribs is increased by the dia- 
phragm being unable to descend, it being so high up 
in the thorax. 

Dyspnoea in Bronchitis: Due to the swelling of the 
mucous membrane and an accumulation of the secre- 
tions in the smaller bronchi. When few bronchi are 
involved, the remaining patent ones compensate. 
There is no subjective, and only slight objective dysp- 
noea, but when many small bronchi are closed there 
is objective as well as subjective dyspnoea. When 
middle-sized bronchi are almost closed, deep, forced 
respiration, slower than nomal, can overcome the 
stenosis, which is the type of respiration seen in fibrin- 
ous bronchitis. In contrast to this, there are cases 
in which the respiration is increased, but not in pro- 
portion to the degree of stenosis. This may be asso- 
ciated with subjective dyspnoea and cyanosis, but if 
there is no expiratory stridor and prolonged expira- 
tion, stenosis below the tracheal bifurcation would be 
indicated. In these cases the respiratory effort is not 
sufficient to overcome the stenosis, and the pressure 
of the expiratory muscles upon the air passages in- 
creases the stenosis. There are many transitional 
forms of this expiratory dyspnoea due to the relation 
of the dyspnoea to the expiratory strength. 



METHODS OF PHYSICAL EXAMINATION 37 

Dyspnoea in Asthma and Emphysema: Bronchial 
Asthma, hke the latter, is a stenosis of the finer bron- 
chi. It is a question whether the stenosis leads to a 
slowing of the respiration through the smaller open- 
ings or if it causes accelerated respiration. 

Emphysema: Due to fixed inspiratory position of 
lung, diminished excursion, diminished alveolar sur- 
face, diminished capillary surface and circulatory dis- 
turbances. In pure uncomplicated emphysema {i.e., 
no enlargement or bronchitis) the dyspnoea is of a 
superficial character, increased by slight exertion. 
As nearly all cases of emphysema are accompanied by 
diffuse bronchitis, usually of the dry character, the 
tendency is to a slowing and deepening of the respira- 
tion on account of the bronchial stenosis, the stiff- 
ness and increase of volume of lung. The degree of 
alveolar destruction varies so with the bronchial con- 
dition that the demand of the organism may cause 
any sort of breathing. In the majority of cases the 
subjective is more marked than the objective 
dyspnoea. 

Urcemic Dyspnoea: Uraemic asthma with slow, long 
breathing is not due to the uraemic condition, but to 
the cardio-bronchial or pulmonary oedema. In this 
condition any form of dyspnoea may be present. 

Febrile Dyspnoea: Artificial heat increases respira- 
tion. Fever may do the same. Toxins may stimulate 
the respiratory centre. The character of respiration 
may vary vastly in different diseases. 

Ancemic Dyspnoea: Due to the diminished oxygen 
carrying power of the blood. In order to compensate 



38 NOTES ON PHYSICAL DIAGNOSIS 

for this deficiency the inspired air must remain a 
longer time in contact with the blood. In pernicious 
anaemia, therefore, the characteristic respiration is 
not only increased in frequenc}^, but also in depth. 
This form of dyspnoea is seen also in diabetic coma, 
due to the fact that the blood does not take up 
oxyg-en readily. 

Mixed Breathing: In rapid respiration the relative 
duration of inspiration to expiration is as the normal. 
In deep breathing the relation is changed and one or 
the other is prolonged. 

Accessory Muscles of Inspiration: In forced expira- 
tion the abdominal muscles are used, while in inspira- 
tory dyspnoea they come into play in hastening ex- 
piration for the next inspiration. 

Dyspnoea and Cyanosis: Dyspnoea tends to lessen 
cyanosis. If cyanosis is present with dyspnoea the lat- 
ter prevents the CO2 accumulation from becoming 
too great. However, the organism is being supplied 
with blood of poor quality and therefore suffers; in 
chronic cyanosis the patient after a time adapts him- 
self to the condition and suffers no subjective 
dyspnoea. This may be due to : the anesthetic action 
of the COo; the more sudden the onset of the cause 
of dyspnoea, the greater the objective and subjective 
symptoms; the more gradual the onset, the less the 
symptoms. 

Voice: Hoarseness due to tumors, to disease or 
injury of the vocal chords, to paralysis, to weakness, 
such as is seen in cachectic or feeble patients; to 
phthisis, in which the hoarseness may be due to the lo- 
cal phthisical process. Hoarseness with inspiratory 



METHODS OF PHYSICAL EXAMINATION 39 

dyspnoea points to stenosis of the larynx; hysterical 
aphonia is never preceded by hoarseness. 

Note. — Hoarseness amounting- not infrequently to aphonia may ac- 
company pleurisy or aneurysm of the aortic arch. In the latter the 
hoarseness is due to pressure on the recurrent laryngeal nerve. — Editor. 

Nasal Voice: Closed form. From stenosis of 
nasal cavities due to polypi, suppuration, hypertro- 
phic rhinitis. 

Open form : Cleft palate ; syphilitic destruction of 
palate. 

Loss of Voice (aphonia) comes from an inability of 
the chords to vibrate or approximate. 

Voice is modified by sex, age, strength, dyspnoea, 
local disease. In heart disease, when the patient is im- 
proving, the voice is stronger ; when the condition be- 
comes graver, the voice is weaker. 

Cough: In considering weakness or loss of voice 
recall the distribution of the vagus sensory nerve. 
The portions of the trachea most sensitive to irritation 
are the inter-arytenoid mucous membrane and that at 
the bifurcation of the trachea. The trachea is next in 
sensibility and the bronchi next. Stimulation of the 
lung parenchyma produces no cough. Stimulation 
of the visceral pleura produces a cough, while stimu- 
lation of that of the parietal pleura will not. 

Rare Cases : Stimulation of the pharynx, base of the 
tongue, and oesophagus. Cold feet will in some in- 
stances cause cough, and drafts on different portions 
of the body are also in some cases influences produc- 
tive of cough. 

There is no true stomach cough. It comes from the 
pharynx or larynx, or perhaps some irritation in the 



4^ NOTES OX PHYSICAL DIAGXOSIS 

nasal cavities. The most likely explanation of stom- 
ach cough proper is that by inflammation or de- 
rangement of the gastric mucous membrane the 
vomiting centre in the bulb transmits a stimulation 
through the respiratory centre. This has never been 
proven or demonstrated. 

Nervous Cough: Is extremely rare. Usually some 
small inflamr.iatory area of the respiratory tract ex- 
ists. 

Paroxysmal Cough. ?.5 seen in ^^'hooping Cough, or 
from foreign bodies, profuse secretions, bronchiecta- 
sis and cavities. The inspiratory whoop in whooping 
cough is due to a spasm of the glottis caused by the 
traumatism it receives. This whoop is rarely, if ever, 
heard in other conditions. From violent irritation of 
the cough centre the stimulus is spread to other por- 
tions of the fourth ^•ent^icle. especially to the vomit- 
ing centre. 

Venous Stasis du: t: Cough: Patients" statements 
as to cough must be duly weighed, as those with 
marked phthisis may complain of no cough or ex- 
pectoration. In such cases the secretions are not in- 
frequently swallowed. 

Disfc}ision by Coughing: Mostly in upper part of 
chest, upper ribs, supra-clavicular foss?e. especially as 
seen late in emphysema, in beginning phthisis, Avhen 
there is distension o^ only one supra-clavicular fossa 
by coughing. Such c?.ses should be regarded with 



XOTE. — Elongated u^•^lla, irritation of fauces and of the auditory 
canal and rvTnpanum are causes of cough. — Editar. 



METHODS OF PHYSICAL EXAMINATION 4i 

LUNGS AND PLEURA. 
Palpation. 

The chest is palpated (felt) in order to detect re- 
sistance, fluctuations, abnormal impulses and frem- 
itus. 

Fluctuations are obtained only in the superficial 
lesions of the chest walls; it is impossible by this sign 
to demonstrate fluid within the chest. 

Pvdsations: Visible and palpable pulsations are 
due to tumors, aneurysms, etc. These, however, can 
best be appreciated with the ear. Pulsation of the 
lung tissue may rarely be felt in marked mitral regur- 
gitation and in pulmonary insufficiency; pulsation of 
a pleural exudate as transmitted from the heart im- 
pulse is rare, as in this condition the soft tissues are 
under tension. In emphysema, where the tissues, due 
to inflammation, have lost their tension, the sign is 
less frequently obtained. If tension of exudate is 
high, it is non-obtainable. 

The most favorable condition in which to obtain 
the sign is when the tension of the fluid within the 
thorax is the same as the atmospheric pressure and 
when the soft parts have lost their tone. 

Vocal Fremitus or Tactile Fremitus: Produced by 

Note. — Some confusion has arisen from the terms vocal and tactile 
fremitus. Vocal tactile fremitus is the vibration {fi-emitus fremare, to 
murmur) of the air in the respiratory passage produced by the voice 
(vocal) and transmitted through the chest and felt by the hand touching 
(tactile) the chest. 

In speaking, therefore, of vocal fremitus, no reference (by most 
authors) is made to what is heard. The voice vibrations as heard are 
spoken of as pectorophony and subdivided into bronchophony, pec- 
toriloquy, and segophony, see note, p. 17. — Editor. 



42 NOTES ON PHYSICAL DIAGNOSIS 

the vibrations of the air passing the larynx; trans- 
mitted through the air in the bronchi to periphery of 
lung through the chest wall to the hand. It is 
best felt where the chest wall is thin, as in the 
supra-clavicular region anteriorly. It diminishes 
from this point downward. As a rule it is more in- 
tense at the right apex than at the left. However, 
many cases are seen in which the condition is the op- 
posite. The theoretical explanation of this greater 
intensity at the right apex is that the right bronchus 
is shorter and larger and is higher than the left. The 
route of the right lung is supposed to be more di- 
rectly in communication with the thoracic wall, as 
heart and vessels are interposed on the left side. Pos- 
teriorly on the right side vocal fremitus is more dis- 
tinct. Here again the condition varies greatly. 

Causes Altering the Intensity: 

Is diminished by thick muscles, fat, loss of elasticity 
of the thoracic walls, loss of elasticity of the lung as 
in emphysema, conditions separating the lung from 
the chest wall as in pleurisy, plastic or effusive, tu- 
mors, air, etc. 

Feeble vibrations of the larynx, as from high or 
weak voice, such as occurs in women or in feeble pa- 
tients, the phonetic character of the word selected, 
the conditions preventing the air from reaching the 
lung, as in stenosis of the bronchus. 

It is increased in thin walled thoraces, consolida- 
tion of the lungs, etc. ; also in infiltrations of the lung 
and in large bronchial cavities. 

The increased fremitus accompanies bronchial 
breathing and voice, but this rule at tim.es undergoes 



METHODS OF PHYSICAL EXAMINATION 43 

a marked modification. In large exudations of fluid 
or in pneumothorax with a compression of the Kmg, 
one gets below the edge of the fluid bronchial voice 
and breathing with no fremitus. In infiltrations a 
bronchus may be closed by secretions or by the 
pressure of tumors, in which case there will be 
neither voice nor fremitus. 

In exudation with compression of the lung one 
may get such a marked fremitus that the whole tho- 
racic wall is thrown into vibration. In this condition 
the fremitus, which is very intense, is below the level 
of the fluid. Bronchial voice and breathing may 
also be present over the same area. This fremitus, 
bronchial voice and breathing, may be very intense 
if adhesions over a markedly compressed lung exist. 
Vocal fremitus is best obtained by light palpation 
with the ulnar side of the hand, never forgetting to 
compare both sides of the thorax. 

Percussion. 
Percussion is either immediate or mediate, ob- 
tained with plexor and pleximeter. 

The essential conditions in percussion are. first: 
apply the pleximeter closely; second: compare both 
sides of the chest; tJiird: strike with equal force on 
both sides; fourth: vary the strength of the stroke 
according to the thinness of the chest and the depth 
of the organ to be percussed; fifth: stand in front of 
the patient. 

There are three vibrations produced: 
Those of the pleximeter, 
Those of the chest wall, 



44 NOTES ON PHYSICAL DIAGNOSIS 

Those of the air in the lung. 

The first is httle marked, the second most marked 
in those with thick chest walls from muscle or fat. 

Stethoscopic percussion or scratching. 

Respiratory percussion. 

Deep inspiration yields a fuller and higher pitched 
sound. Deep expiration is the opposite. 

Attributes of percussion sounds : 

The Quality of the note depends upon the com- 
position of the instrument producing it. For exam- 
ple, the violin note differs in quality from that of a 
piano. Over the normal chest we have three quahties 
of note : (i) the vesicular resonance, resonant note due 
to the vibration of air in the vesicles ; (2) dull; (3) tym- 
panitic in altered organs. The first is best obtained at 
the left infra-clavicular fossa. It varies with, first 
the thickness of the chest wall; second, intervention 
of bone; third, adjacent viscera; fourth, the force of 
the percussion. 

Intensity means loudness, is increased in (i) thin- 
ness of the chest wall ; (2) force of the percussion. 

Duration means the length of the sound and varies 
inversely with the pitch. The higher the pitch, the 
shorter the duration. 

Pitch: High, intermediate, low. 

The higher the tension of a cavity be, the more 
numerous will the vibrations be, and the higher the 
pitch will be, but the shorter the amplitude of the 
vibrations and the less will the intensity be. 

In the normal lung the air vesicles are under little 
tension and the resonance is of a low pitch. If the 
lungs are distended, we get a high pitch with a tym- 



METHODS OF PHYSICAL EXAMINATION 45 

panitic quality, the vesiculo-tympanitic resonance of 
Flint. This is heard in distended lungs in acute com- 
pensatory emphysema. 

Tympanitic sounds vary in pitch, increasing in- 
versely with the size of the cavity and directly with 
the degree of tension. For example, the stomach 
usually gives a lower pitch than the intestine, but a 
markedly distended stomach gives a higher pitch 
note. In great distension the tympany may be lost. 

Diilness and Flatness are high pitched. Beginning 
infiltration gives a higher pitched note than normal. 
Below the right clavicle one gets over the normal 
lung a higher pitch than below the left. The causes 
are, first: the root of the lung is higher; second: the 
muscles of the right side are greater; third: the pres- 
ence of the liver. 

Didness is absence of resonance or air. Denotes 
presence of a fluid or solid. It differs from flatness in 
degree : Slight, moderate, or marked. 

Topographical Percussion Ride: In differentiating 
dull from resonant percussion, use light percussion. 
This keeps the deeper and lateral areas from being 
set in vibration. The point always to be kept in mind 
is that light percussion means more light application 
of the pleximeter than lightness of stroke; deep 
percussion does not mean violent blow, but merely 
a moderate blow, with a distinct pressure of the ap- 
plied finger. By too violent a stroke or too hard 
pressure of the applied finger, a greater area of thorax 
tissue, etc., is thrown into vibration and a false result 
is obtained. The old idea that dull areas were found 
nearby tympanitic portions has been disproved by 



46 NOTES ON PHYSICAL DIAGNOSIS 

this method. This rule has to be altered in oedema- 
tous, fatty or muscular people, especially in regard to 
light percussion. Deep percussion never gives abso- 
lute dulness, but relative. Light percussion gives ab- 
solute and also relative. The normal body differs 
from, the cadaver in that in the latter the tissues have 
lost their elasticity and the organs have changed 
their position. 

Flatness is a term used to denote absolute loss of 
resonance. 

Tactile Percussion: Is an increased sense of resist- 
ance to the finger. This is a valuable differential 
quality. 

Tympany is a sound produced by percussing over 
a cavity filled with air whose walls are neither too 
tense nor too yielding. 

Variations in the normal chest : 

Above Clavicles: The best vesicular resonance is 
obtained from above the middle of the clavicles; at 
the inner end of the clavicle the note becom^es tym- 
panitic, due to the trachea ; at the outer end the note 
is dull. 

Over Clavicles: At the middle of the clavicles a 
resonant note is given; at the outer end a dull note, 
and at the inner end the note is high pitched. (The 
osteal note.) 

Belozi' Clavicles (Infra-Clavicular) : On the left side 
the normal resonant note is obtained, while on the 
right side the note is higher pitched, shorter in dura- 
tion and less clear. This is not always the case. 

Right Sternal Line: The thickness of the muscles 
varies the note on both sides. Between the third and 



METHODS OF PHYSICAL EXAMINATION 47 

the fifth rib, one gets the relative duhiess of the 
heart, absolute dulness of the liver at the sixth rib, 
and relative dulness at the fifth. 

RicrJit Mammary: At the fifth rib the note is raised 

o 

in pitch and diminished in intensity, due to the rela- 
tive dulness of the liver; at the sixth the note is flat. 

Left Sterml Line: At the third interspace there is 
the relative dulness of the heart ; at the fourth rib ab- 
solute dulness, which extends to the sixth rib. 

Note. — Below the sixth rib stomach tympany is given (semilunar 
space of Traube see also page 66) — Editor. 

Sternum: In the sternal notch the tympany of the 
trachea is given. From upper sternum to the third 
rib one gets a resonance bordering on tympany, due 
to the trachea. From the third to the fourth rib one 
gets the pure lung note. From the fourth to the 
sixth rib one gets slightly diminished resonance, due 
to the heart, although the lung lies under the ster- 
num. This is more marked at the left edge of the 
sternum. At the sixth rib one gets liver dulness or 
flatness. 

The Axillary Spaces: There is good resonance on 
both sides in the mid-axiflary line; on the right 
side, at the eighth rib, one gets relative and at the 
ninth rib absolute liver dulness. On the left, at the 
ninth rib, the spleen is reached and extends to the 
eleventh rib. The spleen extends backwards on the 
tenth rib as axis for two or three inches, and is lost in 
the muscles of the back. The stomach, where it lies 
behind the lung, gives a clearer note to the lung than 
does the liver in a corresponding situation on the 
left. 



48 XOTES ON PHYSICAL DIAGNOSIS 

Posteriorly: The position of the patient greatly in- 
fluences the character of the note obtained. 

Supra and Infra-spinoiis Fossa: The resonance is 
diminished on account of the bones and muscles, but 
comparison of the two sides can be better carried out 
in this situation than in front. 

Inter-scapular Region: Better resonance is obtained 
in this region than in the supra and infra-spinous 
fossse, but not so good as in infra-scapular region. 
At the upper portion the tympany of the trachea may 
influence the note. 

Infra-scapular Region: The note here more nearly 
approaches that of the normal as obtained in the left 
infra-clavicular. 

RigJit Scapular Line: The relative dulness of the 
liver is found at the ninth rib ; the absolute at the 
tenth. 

Left Scapular Line: The resonance extends to the 
tenth rib. It ma}^ be influenced by the tympany of 
the stomach or colon, or the dulness due to the pos- 
terior portion of the spleen. For the same reasons 
the resonance on the right side may be slightly higher 
pitched and of less intensity, due to a greater muscu- 
lar development. 

Remember the lungs move an inch or more on 
deep inspiration and expiration. 

Kidneys: The left is higher than the right. The 
dulness of the kidneys cannot be differentiated from 
that of the liver and the spleen, nor the dulness of 
inner borders of the kidneys from that of the spine. 

The anterior border is three to four inches from 
the median line and is limited by the tympany of the 



METHODS OF PHYSICAL EXAMINATION 49 

colon on the left and of the stomach and colon on 
the right. 

Lower borders can be defined by the line of tym- 
pany of the colon just above the crest of the ileum. 

Abnormal Sounds: Vesiculo-tympanitic (Skoda's 
or Flint's) resonance. The quality of this note is 
composed of a vesicular and a tympanitic element. 
The pitch is higher in proportion as the tympanitic 
element predominates over the vesicular and the in- 
tensity is increased. It is due to a relaxation of the 
lung tissue. There may be either one of two forms 
of relaxation. 

Mediate relaxation, as relaxation of lung in pleu- 
risy, pneumothorax, lobar pneumonia (second stage). 
In pleurisy with a small amount of fluid Skodaic re- 
sonance is obtained just above the fluid, due to the 
relaxation of the lung. 

Immediate relaxation, as relaxation of lung in em- 
physema, acute over-distension of the air vesicles, 
asthma, effusion of fluid into alveoli without complete 
consolidation, as in pneumonia (first and third stage), 
oedema, portions of lung near consolidated areas, 
early phthisis (disseminated form), gangrene and 
abscess of lung. 

Pure Tympanitic Resonance: Is found normally over 
the larynx, trachea and the left infra-axillary area, 
due to the stomach."^ The larger the volume of air 
the lower the pitch ; the smaller the transverse open- 
ing to the cavity the higher the pitch. 

* These are all normal cavities containing more or less air, and the 
signs obtained over them may be taken as expressive of the signs of air- 
containing cavities in general. The variations of voice sounds may be 
also tested over these areas. — Editor. 
4 



so NOTES ON PHYSICAL DIAGNOSIS 

Wintriclis Sign: One gets a higher pitched note 
when mouth is open than when closed, while per- 
cussing over a cavity. If change of note is not ob- 
tained lying down, but is on sitting up, it shows that 
in the first position the opening to the cavity is ob- 
structed. For illustration percuss over the thyroid. 
This latter will, of course, not present any difference 
in the note on changing from the sitting to the lying 
position. 

GcrJiardfs Change of Note: One gets a higher 
pitch in percussing over the long axis and a low pitch 
over the short axis of the cavity. 

Tympany is found in pneumothorax if tension in 
cavity is not too great. 

Biermers Change of Note: When patient stands, 
the diaphragm is depressed and the cavity is enlarged 
and one gets a lower pitch than when the patient 
lies down. 

Williams' Tracheal Resonance: Is produced by per- 
cussing over consolidated lung near a large bronchus. 
The note obtained in this condition approaches the 
tympanitic in character. This note is also heard over 
the compressed lung above large pleural effusions. 

Amphoric Resonance: Is a note of an echoing char- 
acter. 

Siiccussion Splasli: Is the splashing of fluid heard 
on shaking the chest of a patient with hydropneumo- 
thorax ; is produced by fluid in a cavity with air. The 
metallic sound is dependent on the tension in the 
cavity, and is heard over a pulmonary cavity, pyo- 
pneumothorax, stomach, cavities at base of lung, etc. 

The Cracked Pot Note: Is a modified tympanitic 



METHODS OF PHYSICAL EXAMINATION 5^ 

sound caused by the expulsion of air from a cavity 
through a small hole. The cavity must be super- 
ficially situated. The mouth of the patient must be 
kept open and the blow must be short and forcible. 
It is sometimes heard in pneumothorax with opening 
into the lung. 

The Metallic Percussion Note: When a coin is placed 
upon the chest of a patient suffering from pneumo- 
thorax and lightly tapped with another coin a clear 
hell-like sound is heard if the ear is placed at the same 
time against that portion of the chest opposite to that 
on which the coin is. The physical requirements for 
obtaining this note are that the space or cavity be of 
sufficient size, the walls smooth and the tension of the 
air within the cavity not too great. This sign is ob- 
tained at certain areas only, and if present may dis- 
appear after the removal of fluid in pneumothorax, 
or appears, if absent originally. This is due to the 
variation of tension within the cavity. The position 
of the patient may bring this tone out, or change its 
character. This is due to changes in the diameters of 
the air spaces, as a result of the moving fluid. In the 
sitting posture, with the fluid pushing down the 
diaphragm, the tone is deep. In the prone position, 
it changes to one of a higher pitch. Always percuss 
the same point on changing the position. Air in the 
prsecordium gives tympany or a metallic tone, chang- 
ing with change of position of patient. Lung cavities 
rarely give metallic tones, as they do not fulfil the re- 
quirements. (See footnote.) As a rule, they are not 
large enough, their walls are too thick and irregular. 



52 NOTES ON PHYSICAL DIAGNOSIS 

and they lie too deep. A diaphragmatic hernia may 
give a metalUc tone. 

Note. — Percussion : Normal vesicular note is that obtained over 
the normal lung; dulness or flatness is that obtained on percussing 
thigh. There are many transitions between these two. The more air 
a body contains, other conditions being equal, such as tension, etc., the 
louder the sound. The deeper the layer of air-containing tissue, or the 
thicker the air-containing parts of an organ, the louder the note. jNIany 
conditions modify the above. The tympanitic note has a musical 
character as distinguished from the normal resonance, i.e., the vibra- 
tions are clear and distinct. Organs which are subject to no tension 
give no tympany ; as the tension increases the pitch rises till the point 
is reached where tension is so high that the note becomes flat. There 
is no adequate physical explanation of this phenomenon. Tympany de- 
pends on the size of the space, the tension of the tissue, the consistency, 
etc., and the tension of the air within the space. It is difficult to distin- 
guish where normal resonance leaves off and tympany begins. One gets 
combinations of dulness with tympany; for example, dull, high tympany; 
dull, low tympany, etc. A metallic or musical note heard especially at the 
latter part of the sound is due to the association of the sounds and is 
caused by the walls of the cavity being smooth and thin and the cavity 
either being without any opening or having a small opening. The 
space, in order to produce this note, must be less than six centimeters in 
diameter. It is difficult to produce and is best heard by percussing 
with a hard object and auscultating at the same time. It may be heard 
over the stomach and colon, also in the space between the lung and 
pleura. — Editor. 

Comparative Percussion. 
Normal lung resonance is diminished by fat, mus- 
cles, the mammary glands, the scapulae, dense or 
hollow organs in the neighborhood; where there is 
marked convexity of the chest, the normal resonance 
is lost, as a convex surface vibrates less readily than 
a flat. This is especially seen in kypho-scoliosis. 
Dulness comes from the interposition of solid ma- 
terial between the normal lung tissues and the thorax 
wall, as exudations, thickened pleura, tumors, con- 



METHODS OF PHYSICAL EXAMINATION 53 

gestions, consolidations, infiltrations, atelectasis, etc. 
Closure of a bronchus with the absorption of air and 
the exudation of fluid. 

This last may be small or large, deep or superficial. 

In mediary infiltrations, early stage of capillary 
broncho pneumonia, diffuse tumor metastases, etc., 
one may have relative dulness, normal or hyper- 
resonant tone. 

Pleuritic Dulness: As a rule the line of dulness in 
pleuritic exudates is obtained from behind, down- 
wards and forwards. This is caused by the elastic 
retraction of the lung upwards and backwards. 

In hydro-thorax, in the early stage, the case is the 
same, but later, as the fluid increases, the line is circu- 
lar about thorax and changes more or less readily on 
change of position of patient. In pleurisy, the case is 
different, as there are adhesions and the line keeps 
its position of obliquity, while the exudate gradually 
moves in the direction of least resistance. In case 
of pleurisy, where the line is horizontal, there must be 
some resistance to the retraction of the lung, such as 
adhesions, infiltrations, etc. 

The dulness of pleuritic exudate is absolute. In 
lung infiltration of the most intense degree, the bron- 
chi contain air to a greater or less degree and give 
slight resonance. Displacement of the heart and liver 
is more characteristic for exudates than infiltrations. 
In left-sided exudations the half-moon space (Traube 
semi-lunar space, see p. 47) is dull, even when the lung 
is in its normal position, and is the best and most posi- 
tive sign of early or slight exudate. It fails only when 
the complementar}^ space is obliterated by old or fresh 



54 NOTES ON PHYSICAL DIAGNOSIS 

pleuritic adhesions. In very excessive exudates, the 
diaphragm can be pushed down to the edge of the 
ribs, or even below, and unless covered by the gut, 
may give dulness to the ribs or below ribs. In some 
cases the exudate moves readily with change of posi- 
tion of patient. This is more frequently met with in 
the serous than in the purulent. In some cases the fluid 
goes about among the adhesions, and in such cases in 
the sitting posture the posterior dulness is lower and 
less intense, while the anterior becomes more intense, 
but not so high. In slight exudates the fluid ma}^ spread 
thinly over the lung, and if this takes place slowly the 
dulness diminishes after the patient has been standing 
or sitting for some time. In the beginning of exuda- 
tions the lung above gives a normal note. As the ex- 
udate increases, the tension of the lung is diminished, 
and the note obtained over the lung area is hyper- 
resonant (Skoda's resonance). As soon as the ex- 
udate compresses the lung, dulness appears, but 
never to the same degree as that obtained over fluid. 
In this last instance one can at times obtain tracheal 
tympany. After absorption a thickened pleura can 
give almost as flat a note as fluid. It must be borne 
in mind that people can have a chronic fluid exudate 
and appear perfectly well, having no subjective symp- 
toms. Care must be taken not to diagnose such cases 
as thickened pleura. Also dulness gives no true idea 
of the extent of the pleurisy, as adhesions to the chest 
wall ma}^ divert the fluid upward and along the spine 
and into the mediastinum. The height of the dulness 
must always be judged by the intensity of the note ; 
relative dulness in this respect indicates nothing, as 



METHODS OF PHYSICAL EXAMINATION 55 

fibrine deposits, atelectatic lungs, etc., may be a 
source of error. Increase of voice and fremitus ob- 
tained over compressed lung at the upper edge of the 
fluid is of the greatest value in determining the extent 
of the exudations. 

HydrotJwrax: The fluid moves rapidly, as a rule, 
with changes in position. This is denied by some and 
Sahli says that the change is slow. In distended ab- 
domen, hydro-thorax may be undemonstrable as the 
diaphragm in this condition being pushed up may ob- 
scure the signs of thoracic fluid. In the upright 
position, if the abdominal walls are weak, the dia- 
phragm is pulled down, and slight fluid accumulation 
becomes more marked. In large transudates, by put- 
ting the patient on his side, signs of fluid may be ob- 
tained along the spine. 

If fluid and air are combined, changing the position 
of the patient readily changes the position of the fluid. 
In slight exudates if the diaphragm is pushed down 
and the fluid is not, in the upright position, demon- 
strable by the above signs, then by bending the pa- 
tient forward an area of flatness can be obtained. If 
the patient w4th pleural exudate lies on his side, the 
area of flatness changes to one along the spine. If 
adhesions are present none of these statements hold 
good. 

Hmnotliorax: It must be remembered that until 
the blood coagulates, which requires some time, the 
signs of hsemothorax are identical with those of 
hydrothorax. Later, because of coagiflation and in- 
flammation with adhesions, the exudate cannot move 
with change of position of patient. 



S6 NOTES ON PHYSICAL DIAGNOSIS 

Consolidation of the Lung: Is never so dull as fluid, 
is not so sharply defined, and is more or less pro- 
gressive in the opposite direction of gravity. Usually 
a hyper-resonant note is obtainable, nearby to 
infiltration. Broncho-Pneumonic areas are usually 
found below and behind, on the edges of the 
lung, in front and at the sides, or at the column 
along the spine. Tu'bercular infiltration at the apex, 
or along the antero-inferior edges of the lung. In- 
farcts are usually posterior and low down. Tumors 
of the lung or pleura give intense dulness, more so 
than infiltration, as there is no air contained in the 
tumor mass. Tumors of the mediastinum give dul- 
ness above the heart area ; if pleural exudate, or thick- 
ened pleura is also present, it is practically impossible 
to make a diagnosis by the physical signs. 

Dulness of cavities is due either to fluid within the 
cavities, to thickened walls, or to infiltrations about 
the cavity area. After free expectoration, the dulness 
may be replaced by tympany or resonance. 

Atelectasis : Due to an obstruction of the large or 
small bronchi. Absorption of air from the alveolar 
spaces and its replacement with exudate. Gives the 
same signs as broncho-pneumonia. A very large 
heart, by compressing the lung, may give signs of 
consolidation at the base of left pleural cavity. A 
dull note may persist, after absorption of a pleural ex- 
udate, due to deposit on pleura and lung. 

Abnormal Hyper-Resonance or Tympanitic Tone: 
(i) Emphysema gives an abnormally loud and deep 
tympanitic tone. (2) Relaxation of the lung tissues 
due to changes in the inter-thoracic pressure from 



METHODS OF PHYSICAL EXAMINATION SI 

tumors, exudate and enlarged heart. Below tuber- 
cular infiltrations or just above pleural exudates 
and in pneumonic conditions also this note is ob- 
tained. In the early stages of infiltration one gets 
hyper-resonance or even tympany over the involved 
area. Early oedema and atelectasis also give this 
hyper-resonance, due to the relaxation of the lung 
tissue. Pneumothorax, as a rule, gives an abnor- 
mally loud tympanitic note, especially if air is under 
moderate pressure. If the pressure of the air on the 
chest is the same as that of the atmosphere one gets 
distinct tympany. In cavities with large thin walls 
surrounded by slight infiltration, one gets the true 
tympany. Very small and numerous cavities or deep 
lying large ones may give the normal tone. Dia- 
phragmatic hernia gives a note which is the same as 
that obtained over the intestine. Tympany from 
oesophageal diverticulum is very rare. 

Auscultation. 

Normal Breath Sounds: Inspiration is always heard; 
expiration may be inaudible or heard at the begin- 
ning of the expiratory act, its duration in this in- 
stance being equal to about one-third to one-fifth that 
of inspiration. This normal vesicular murmur not 
only proves that air is in the lung, but that it is circu- 
lating. Theories: (i) is produced by the friction in 
the air against the smaller bronchi and infundibula; 
(2) is produced in the larynx and transmitted through 
the air within the bronchi. 

In opposition to this theory is the following : The 
absence of the murmur in bronchial stenosis. The 



58 NOTES ON PHYSICAL DIAGNOSIS 

increase of the murmur in overaction of local parts 
of the lung. Diminished breathing over adhesions, 
where lung mobility is restricted. In stenosis of the 
larynx a loud noise is heard at the larynx, and practi- 
cally no murmur over the lung. 

According to Sahli, the normal pulmonary vesicu- 
lar murmur is produced by the contractions of the 
heart, independent of the respiratory movement. 

With infiltrated lungs there may be a vesicular 
without any laryngeal murmur. Whether this is due 
to the friction of the air in the small tubes SahH does 
not state. He believes that the stretching of the 
elastic alveolar walls, one after the other, produces a 
vibration, and that this is the cause of the murmur. 
He compares this to the murmur produced by the ex- 
pansion of a dry sponge. 

Physiological Bronchial Breathing: Is of a high 
pitched blowing character. Expiration is louder than 
inspiration and longer in duration. Is caused by the 
larynx, the laryngeal chords being closer together in 
expiration than in inspiration, thus causing a higher 
pitched note. Expiration is a longer process physio- 
logically than inspiration, thus accounting for the du- 
ration. This physiological laryngo-tracheal murmur 
varies in different individuals. It differs from the 
pathological in that it is always accompanied by a 
vesicular murmur and is best heard over the sternum 
between the scapulce and at times at the right apex. 
It is increased when vesicular breathing is weak or 
absent. 

Decreased Vesicular Breathing: Varies with the 
depth of the breath and the area auscultated. For ex- 



METHODS OF PHYSICAL EXAMINATION 59 

ample, at the apex and edge of the lung. The lung 
structure being thin at these points a weaker mur- 
mur is heard than over the thicker parts of the lung. 

Increased Vesicular Murmur: In thin chest wall, 
and in children. Children have a louder murmur, 
mixed with a little bronchial quality; the so-called 
puerile breathing. 

Increase in Pitch: Is heard in catarrh of the finer 
bronchi. This favors the theory of Laennec, that the 
vesicular murmur is produced by friction in the 
sm.aller bronchi. Increased intensity of vesicular 
murmur is also heard in all conditions of relaxed 
lung tissue, beginning pneumonias, in the neighbor- 
hood of infiltrations and near conditions diminishing 
the cavity space of the chest, as small multiple infil- 
trations, tuberculosis at the apex, while over the 
adjoining normal portion of the lung the murmur 
is faint as the lung is here thin. It is diminished 
in all conditions of diminished or decreased ex- 
pansion of the lung. Weakness or absence of fJie 
vesicular murmur: (i) Stenosis of the larynx or 
trachea, stenosis of the bronchi, capillary bronchitis. 
(2) Obstruction to the lung expansion, pleuritic adhe- 
sions, multiple infiltration, causing a stifi^ness of the 
lung tissue, tubercular infiltrations with dulness where 
bronchi are closed, and due to inflammatory infiltra- 
tion of the walls. (Seen very often.) Pleuritic eft'u- 
sions, where one side or a portion of the chest wall 
does not move. Pain acts similarly. In emphysema, 
where the lungs are so large that there is little ex- 
pansion. Bronchitis plays a secondary role in this 
respect, but aids in diminishing the intensity and in 



6o NOTES ON PHYSICAL DIAGNOSIS 

changing the quahty of the murmur. Separation of 
the lung from the chest wah, as in thickened pleurre, 
air, exudates and tumors. 

Prolonged Expiration: Is a frequent, but not a con- 
stant accompaniment to harsh vesicular murmur. Is 
seen in bronchitis, where there is some slight stenosis, 
due to the catarrh. It takes longer for the air to 
pass the narrow opening, and therefore greater force 
is required for its expulsion. This condition can be 
either local or general. Emphysema or asthma or 
both generally exist when this sign is present. AVhen 
local it is a suspicious sign of tuberculosis. 

Rough Vesicular Breathing: Must not be confused 
with increase in intensity of murmur. The latter is 
a very pure, intense, smooth sound, while the rough 
breathing is much more indistinct and lacking in 
character. This is also a sign of bronchial catarrh 
and verges on the sound produced by distant mucous 
rales. It can sometimes be separated from the vesicu- 
lar murmur. It is produced in the bronchi by tena- 
cious secretions. 

Cog Wheel BrcatJiiug: AA^hen heard over one or 
both lungs it is due either to aneurysms, certain 
forms of pleurisy, or fatigue of the respiratory mus- 
cles. When local it is due to bronchitis, with a valve- 
like obstruction of the air, or to diminished expansile 
power of the lung, as in local pleuris}^ It must be 
distinguished from the normal vesicular murmur in- 
terrupted by other pathological or adventitious 
sounds. This condition is hard to distinguish from 
the so-called indefinite and rough breathing. 



METHODS OF PHYSICAL EXAMINATION 6i 

BroncJiial Breathing: Is heard over parts of the lung 
where no physiological bronchial breathing is to be 
heard. It is due to infiltrations, compressions, cavi- 
ties and fusiforml}^ dilated bronchi. There are two 
theories: (i) That solid lung conducts laryngo-tra- 
cheal murmur better than the air vesicles. This is 
not tenable, as, when bronchi are closed by secretions, 
etc., one hears no breathing over the involved area. 
Transmitted brcncJiial breathing may be due to (i) Bron- 
chial breathing in one part of the lung, increasing the 
laryngo-tracheal murmur over the whole thorax. 
(2) Air passing a bronchus leading to a consolidated 
area acts in the same way as when one blows over the 
top of a bottle. Bronchial breathing due to compres- 
sion is heard so long as bronchi are open. The ex- 
tent of the compression can be gauged by the type of 
bronchial breathing. 

Closure of a bronchus with the absorption of air in 
the lung tissue gives no bronchial breathing. A cav- 
ity or dilated bronchus produces a louder sound, as 
the vibration is local. This is aided by conditions of 
infiltration about the lesion. Deep breathing and 
coughing by displacing the secretions vary the char- 
acter of the bronchial breathing. Bronchial breath- 
ing can vary in quality and pitch as the vowels a, e, i, 
0, II. 

Amphoric Breathing ^ is of a deep bronchial charac- 
ter, with a metallic tone. As a rule a cavity must be 
larger than six centimeters to obtain this type of 
breath sound. The deep bronchial breathing can 

* Amphora, a jar. This breathing is like the sound produced by 
blowing- over the mouth of a jar. — Editor. 



62 NOTES ON PHYSICAL DIAGNOSIS ■ 

readily be mistaken for amphoric. Amphoric breath- 
ing is said to be metalhc when the metallic tone ex- 
ceeds the deeper ground tone. Sometimes over an 
infiltrated lung one gets amphoric breathing. The 
cause is unknown. Over the base of the lung in pneu- 
monia one may get the metallic tone of bronchial 
breathing, due to a distended stomach or colon. The 
position of the mouth in deep breathing can produce 
amphoric or cavernous breathing over areas of nor- 
mal bronchial breathing. This can be distinguished 
from pathological conditions by varying the position 
of the patient's mouth. 

Metamorphosed Breathing: Either begins as vesicu- 
lar and changes to broncho vesicular, or begins as 
bronchial and is lost in vesicular. Bronchial breath- 
ing may also change its pitch, and bronchial may 
change to amphoric breathing. These changes all 
take place in one phase of respiration, as inspiration 
or expiration alone. It is supposed to be due to an 
irregular filling of the cavities with air or to a lack of 
expansibility in the infiltrated lung. 

Indefiiiite breathing is always faint. It is not loud 
enough to give a character. Is heard in pleural effu- 
sions. 

The vesicular murmur may be overshadowed by the 
murmurs transmitted from other portions or local 
rales. In a word, it is a murmur with no definite 
character. 

Mixed or Broncho-Vesicidar: Inspiration vesicular, 
expiration bronchial. Inspiration broncho-vesicular, 
expiration bronchial. Both the vesicular and bron- 
chial breathing are not produced in the same part of 



METHODS OF PHYSICAL EXAMINATION 63 

the lung. The one or the other is transmitted, as in 
sHght irregular infiltrations, near consolidations, near 
compressions, and near cavities. The vesicular ele- 
ment has transmitted through it a bronchial element. 

Rales. ^ Mucous Rales are moist or dry, according 
to the character of the secretion. Are due to a vi- 
bration of the mucus in the bronchi. Can be heard 
in other parts of the chest than where produced, but 
it is easy to locate their place of origin. Coughing 
and deep breathing alter them, and it is a very good 
plan to examine suspected tuberculosis cases before 
they rise in the morning and before the}" have 
coughed or taken deep breath. 

Moist Rales: Large and small. Can be produced 
artificially by blowing with varying strength through 
tubes of varying size containing fiuids of different 
consistency. These are produced by air passing 
through a fluid, such as the secretions of the bronchi. 
They are produced by the air setting in vibration lay- 

* Rales are an evidence of an inflammatory process of the pleura or 
air passages — they are never heard over the normal lung. 

By taking note of the character of the sounds heard the stage of in- 
flammation may in a general way be determined. A " cold in the head " 
may be taken as an example of the stages in the formation of the exu- 
date in the respiratory passage. The slight exudate at the beginning to 
the thick purulent discharge later will, when moved by the respired 
air, yield sounds diff'ering with the amount and character of the exudate. 
By observing also the location at which these sounds are heard, and 
whether they are changed in character by coughing and deep respira- 
tion and whether heard with inspiration, expiration, or both, the por- 
tion of the lung involved together with the stage of inflammation can be 
ascertained. 

The only occasion when rales may be said to be present normally is 
when heard at the apices or lower axill?e on the first or second deep 
inspiration after quiet breathing. These occur at the end oi deep in- 
spiration and unless pathological are not constant. — Editor. 



64 NOTES ON PHYSICAL DIAGNOSIS 

ers of mucus on the bronchial walls. Large rales in- 
dicate involvement of large tubes, with much mucus. 
Small rales the opposite. These rales are heard both 
in inspiration and expiration, but better in inspiration, 
as the inspiratory movement is quicker and more vio- 
lent. Smaller rales are more numerous, as the smaller 
bronchi are greater in number. When fine rales are 
heard constantly in a localized position, one can say 
with certainty, without other signs, that tuberculosis, 
broncho pneumonia, infarct or bronchiectasis is 
present. When widely spread, they are of less im- 
portance. Large mucous rales, Avhere no large bron- 
chus is, indicates enlarged bronchi or cavity. At the 
apex it usually means cavities. At the base, when 
associated with broncho-vesicular breathing, it indi- 
cates bronchiectasis. It must be kept in mind that 
these large rales can be widely transmitted. This is 
true also of local infiltrations. In haemorrhage or 
oedema the rales are fine, the inspiration and expira- 
tion being of the same character, the so-called con- 
tinuous rales. The moist rale is one associated with 
acute, severe diseases of the lung, and when located 
at an apex means a rapid process. The usual bron- 
chial secretion is tenacious, and produces the so- 
called dry rale. The moist is associated with marked 
exudation. 

The Dry Rale differs from the moist in that it is 
not so regularly continuous, but is single and irregu- 
lar, and may have a musical or whistling character. 
They are produced by the tearing or stretching of 
mucus and differ from the moist in that after the first 
vibration they are not able to regain their former po- 



METHODS OF PHYSICAL EXAMINATION 65 

sition before the next respiratory acts. They do not 
therefore occur with every respiratory act, but only 
with every second, third or fourth act. In inlikra- 
tions of the lung, the tissues themselves may pro- 
duce this crackle. 

Musical Rales may be produced by (i) Tenacious 
mucus or membrane. (2) Swollen mucous membrane 
and deposits of secretions producing a stenosis of the 
smaller bronchi. (3) Compressed bronchi close to- 
gether. These have the same significance as the 
moist, and as a rule can be palpated on the chest 
walls, as rhonchi. Are usually widely transmitted 
(Sahli). 

Crepitant Indux and Crepitant Redux: Heard in all 
beginning lung inflammations or infiltrations from 
any cause whatsoever. Are produced by the swollen 
alveolar walls being pulled apart, the fluid exudate 
playing a secondary role. They can be produced in 
the lung of the cadaver. They are also heard at the 
base of the lung of those that breathe superficially. 
In the latter case they soon disappear after two or 
three deep breaths. They are also 'heard on inspira- 
tion. When heard on expiration, they are due to 
air being pumped into a portion of the lung which 
on inspiration was insufihciently inflated, as heard in 
adhesions, near infiltrations, and especially in pneu- 
monia. 

Cardio-Pneumonic Rales * produced by the systole of 
the heart: These can vary from vesicular breathing 
to cavernous and simulate any form of rale. It is 

* If of a murmurous character, are called cardio respiratory mtirnnirs. 
— Editor. 

5 



66 NOTES ON PHYSICAL DIAGNOSIS 

thought by some that diastole can produce a murmur, 
but this is uncertain. 

Pleural Sounds: Are produced by roughness or 
dryness of the pleural surfaces. The further one goes 
from the hilus, that is, towards the more mobile por- 
tion, the better one hears these sounds. When heard 
at the apex, it is due more to centrifical distension of 
the lung than to displacement of the lung tissue as a 
whole. The sound, according to roughness, can be 
heard on inspiration and expiration, or both. It is 
best represented by laying one hand on the ear and 
rubbing the back of the same with the finger of the 
other. The murmur may be like any of the rales in 
the chest. 

Friction Rub, so-called nezu leather rub: The chief 
characteristic of this sound is that it is not continuous 
throughout the respiratory phase, but occurs with 
pauses between. It is of a dry, creaking quality, and 
differs from the moist, mucous rale in that it is heard 
close to the ear and is not influenced by coughing. 
In some cases it can be increased by pressure on the 
chest and is even at times palpable. The friction rub 
dift'ers from the crepitant rales in that the former is 
heard both in inspiration and expiration. At times it 
is impossible to distinguish whether a sub-crepitant 
rale is produced on the pleura or on the lung tissue. 

External Perieardial Pleural Rales are synchronus 
with the heart beat and independent of the respira- 
tion, save that they are usually intensified on deep 
inspiration. Pleuritic rales are heard at the begin- 
ning and end of pleural inflammation before the 
formation of and just after the absorption of the ex- 



METHODS OF PHYSICAL EXAMINATION 67 

udate. \Mien present at tiie upper border of the 
fluid, they are due either to a dry pleurisy above the 
incapsulating adhesions of the fluid, or else to an 
atelectatic lung, but when heard below the level of 
the fluid, they are due to adhesions at this point or 
are transmitted through the chest wall from above. 

The reappearance of rales below the line of dulness 
shows beginning absorption of fluid, the dulness re- 
maining above on account of thickening of the pleura. 
Transmitted pleural rales are not palpable. The rales 
of interstitial emphysema are similar to the fine mu- 
cous or crepitant rales, but with a metallic quality. 

J^oicc Sounds. BronclwpJwny: Is heard over the 
lung normally where the large bronchi are situated. 
Normal bronchial breathing and bronchophony are 
heard over the same areas. It diminishes as one 
descends on the lung. Its presence indicates con- 
solidation or cavity formation. It may be increased 
and have a metallic tone, and in some people it is 
louder than in others, especially at the right apex. 

Pectoriloquy is not necessarily a sign of cavity, as 
it is also heard over consolidations. 

Where the area of infiltration is small, w^hispered 
voice, however, can be demonstrated when all other 
signs fail. 

Mistakes in Auscultating: Hair on the chest may 
simulate crepitant rales. If they interfere moisten 
them with oil or water. The tone produced by mus- 
cular contraction simulates rough breathing or rales, 
especially at apex. In shivering from cold, the muscle 
tone is produced before the tremor can be seen or felt. 
On auscultating above the clavicles with stethoscope, 



68 NOTES ON PHYSICAL DIAGNOSIS 

especially in those using accessory muscles, an irregu- 
lar murmur is produced in the sterno-cleido-mastoid 
muscle, similating rough breathing or crepitant rales ; 
fat, especially that of the mammary gland, may also 
similate these sounds. Friction of the stethoscope on 
the skin, against the clothes or the rustling of the 
clothes themselves may be a source of error. 

The lung area in children and in the senile is usually 
enlarged. 

The Active and Passive Mobility of the Lung: The 
lung moves on deep inspiration and expiration 
eight cm., practically three fingers. The absolute 
dulness of the heart will disappear in thin people or in 
those with strong abdominal walls. The liver-lung 
line is lower on the dorsal position than in the upright 
position. In those with a pendulous abdomen, the 
liver not being supported by the abdominal muscles, 
is lower in the upright position than in the dorsal. 
Changing from the dorsal to the lateral position, the 
lung moves downward three to four centimeters. 
This normal mobility of the lung is diminished in 
emphysema, fibrous conditions and infiltrations of the 
lung tissue with adhesions, all forms of oedema and 
congestion. It is suspended entirely by adherent 
pleura, by adhesions of the complementary spaces. 
In demonstrating the mobility of the lung ordinary 
respiration must not be used, nor, on the other hand, 
should forced respiration alone be employed, as this 
latter tends to inflate the lower edges of the lungs 
and thus gives pulmonary resonance at an abnormally 
loAv point. Forced inspiration and moderately forced 



METHODS OF PHYSICAL EXAMIXATIOM 69 

expiration should be employed. Use light percussion, 
as by deep percussion a larger portion of thorax is set 
in vibration and the lung resonance thus transmitted 
downward. 

Ahnonnal Positions of the Lung: In emphysema, 
the apices are higher. The heart is covered, and the 
lower limits are deeper. Sometimes in fat people and 
in those with strong abdominal muscles, this lowering 
of the lung border cannot be demonstrated, but over 
the heart the enlargement is evident. 

Local emphysema from various causes gives local 
changes, such as is obtained in true emphysema. In 
mitral disease, asthmatic attacks or capillary bronchia 
tis, the lungs are enlarged and decreased in elasticity, 
as is shown by their diminished excursion. Enterop- 
tosis and congenital floating tenth rib give a low posi- 
tion of the lung. The lung area is diminished by ab- 
dominal accumulations, and all those conditions which 
tend to displace the diaphragm upwards. Pericardial 
accumulations and hypertroph}^ of the heart displace 
the lung to the side. If this last is great enough to 
perceptibly diminish the negative pressure in the 
thorax, the lower border of the lung retracts and we 
get all those signs of atelectasis. 

Conditions in the Lung Itself Causing Contractions: 
Tubercular pleuritic thickening, etc., preventing lung 
from retaining its normal position. 

Retraction of the Apex in Tuberculosis : The size and 
shape of the thorax altering the tension of the lung 
tissue and irregularities in the outline may lead to a 
false diagnosis. 



70 NOTES ON PHYSICAL DIAGNOSIS 

HEART. 
Inspection and Palpation. 

Use the flat of the hand to determine the general 
character of the cardiac impulse, then the finger, to 
locate the apex beat. 

TJw Normal Apex Beat: The apex is located in one 
or two intercostal spaces. Towards the base, in the 
mid-clavicular, a post diastolic sinking is som.etimes 
seen. The first corresponds with the outer area of the 
heart dulness; but if the heart is covered with the 
lung, the apex that is seen is within the true limit of 
the cardiac dulness. Its position in health is the fifth 
interspace, in the fourth in children, in the sixth in 
the old. In a healthy adult it has a variation of an 
interspace upward or downward ; in very small chil- 
dren it may be outside of the mid-clavicular line. The 
size varies, but it is usually two centimeters square. 
As a rule the apex has a thin tongue of lung inter- 
posed between it and the thoracic wall. At times -it 
may lie behind a rib, when no impulse w^ill be visible 
on the chest wall. In enormous right heart enlarge- 
ments the apex is made up of right ventricle. The 
apex varies greatly, due to the thickness of the tho- 
racic walls, to fat, muscle, oedema, etc. An absence 
of impulse is not necessarily an index of disease. 

With normal respiration, the apex does not move, 
nor is its distinctness influenced. When an indiv- 
idual lies on the right side, the apex may disap- 
pear, due to the lung moving over and covering it. 
Lying on the left side intensifies the impulse. The 



METHODS OF PHYSICAL EXAMINATION 7^ 

movements of the heart itself must be taken into con- 
sideration. In bending the patient forward the apex 
lies closer to the thoracic wall and appears stronger. 
In deep expiration, the lungs retract, and unless the 
patient strains violently, the apex will disappear, as 
the deep expiration without muscular effort dimin- 
ishes the flow of blood to the left heart, thereby 
diminishing the intensit}' of the apex beat. Neuroses 
and muscular action increase the force and breadth 
of the apex. Keep in mind that the normal apex beat 
comes before the blood has left the ventricle. 

Note. — Students should cultivate the habit of looking not only for 
" the apex beat," but for Impulses — determine how many there are, their 
location, and the maximum of these. Normally there is usually only one 
such impulse. When there is more than one in the normal heart, the 
maximum is that of the apex. In the diseased heart or vessels the max- 
imum is by no means always the apex. " Point of maximum impulse " 
should therefore be spoken of in preference to "' apex beat." — Editor. 

Pathological Apex: The apex is displaced by an 
enlarged heart, either from dilatation or hypertrophy. 
Dilatation of the right ventricle displaces the apex 
outward and on account of the slant of the diaphragm 
downward. In atrophy, the apex may be displaced 
inward. This is rare. In very large right hearts, 
where the apex is produced by the right ventricle, 
there is a displacement outward, and as a rule down- 
w^ard, but as the enlargement is mostly over the dome 
of the diaphragm, the apex is not displaced down- 
ward as much as is seen in dilatation of the left heart. 

Displacements of the Heart due to Pathological Con- 
ditions outside of the heart : Situs inversus : The 
apex is in the same position as the left, but situated 
on the right side. 



72 NOTES ON PHYSICAL DIAGNOSIS 

Eniphyscma: The apex is lower and is placed in- 
ward on account of the low diaphragm. 

Right Pleural Exudate: The apex is displaced up- 
ward and to the left, due to the diminished negative 
pressure. Compensatory emphysema must be re- 
membered as a factor in this displacement. 

Left Pleural Exudate: The apex is lost or displaced 
to the right. 

Diminished intra-thoracic pressure from any cause, 
ascent of the diaphragm from this cause also, or from 
increased abdominal pressure, are conditions which 
all tend to displace the apex upward. 

Increase in the Force and Size of the Apex: Increase 
in force and size within certain limits is normal. This 
increase occurs in febrile conditions, Basedow's dis- 
ease, from tobacco, alcohol, and other toxic agents; 
after exercise and in nervous palpitation. Dilated 
heart may give the impression of an increase in force 
of the apex beat, although signs of cardiac failure are 
present. This is due to the lung having been displaced 
and the heart lying close to the thorax. The apex 
impulse occurs during the closure time. The 
strength of the heart being used up during the closure 
period, less strength is left for the output of the 
blood; for this reason the closure time is prolonged, 
the heart being close to the thorax for a longer time 
than normally, and giving the appearance of a strong 
impulse. This is frequently met with in failing com- 
pensation. On the other hand, when the heart is 
strong, the closure time is very short, as the heart 
readily overcomes the pressure in the vessels. It is in 



METHODS OF PHYSICAL EXAMINATION 73 

contact with the thoracic walls, sinking back during 
the propulsion period. Such cases give a very quick, 
sharp apex beat. These are seen at times in aortic 
regurgitation, where the characteristic heaving im- 
pulse is absent. It also occurs not infrequently in 
mitral stenosis. A distinct, strong apex beat is met 
with in any condition which causes the lungs to re- 
tract. The slow, heaving apex beat is characterized 
by slow heart action, an impulse limited in ex- 
tent and very forcible. This is due to the pro- 
longed closure period and to the marked resistance 
in the arteries, etc. The characteristic feature is the 
slow, powerful impulse at the apex area. An ex- 
cessive filling of the ventricle would give the same 
conditions approximately as aortic regurgitation. A 
vibration felt at the apex and simulating a thrill may 
occur with a violent, quick heart action, and is felt 
in nervous palpitation and powerfully acting hearts. 
Weakening of the Heart Apex: The apex may be 
absent when marked emphysema exists ; also with 
pericarditis, left pleural exudate, left pneumothorax, 
ard w^ith tumors or air in the anterior mediastinum. 
GEdema of the thoracic wall, excessive deposit of fat 
or a muscular thoracic wall may also be a cause of 
a weak cardiac impulse. The absence of an apex beat 
in pericardial effusion is of value only if the apex beat 
Avas noted before the attack. The apex impulse may 
be present with pericardial exudate, if adhesions bind 
the heart to the thorax, or if the exudate sinks to the 
side and leaves the heart free. In excessive heart 
weakness the apex disappears, due to the lack of 



74 NOTES ON PHYSICAL DIAGNOSIS 

power to produce the closure period, as a very weak 
heart may produce a marked apex impulse. The apex 
impulse, however, is often normally weak or absent. 
On this account the sign is an uncertain one. The 
pulse and other signs and symptoms are of greater 
value. When a distinct apex is found within the limit 
of absolute cardiac flatness, it suggests pericardial 
exudate. This phenomenon is also seen in mitral 
regurgitation, in which the heart has no true closure 
time, the apex beat being visible only when a certain 
degree of intra-ventricular pressure is reached. 

Systolic Sinking: Normally a retraction of the 
apex with systole which has no definite explanation 
is sometimes seen. Sahli thinks that these are cases 
of absent apex beat, and what is seen is that part of 
the heart inside and above the apex which normally 
retracts with systole. Systolic sinking is said to be 
due also to adherent pericarditis. It is caused only 
by adhesions of the heart, pericardium or lung to the 
thorax. This is a rare pathological finding. Hyper- 
trophy, dilatation and pericarditis may change the 
form of the heart contraction so that the apex is di- 
verted backwards, thus exerting a negative pressure 
on the thorax and allowing the atmosphere to press 
the interspaces inward. This is frequently seen in 
aortic regurgitation. Many cases of adherent peri- 
carditis never have this retraction of the apex. It is 
an unreliable sign. Occasionally a retraction of the 
lower portion of the sternum and interspaces occurs 
with a large heart and associated emphysema. The 
exact explanation of this is not clear, but it is cer- 
tainly not due to adhesions. 



METHODS OF PHYSICAL EXAMINATIOX 75 



Percussion. 

Absolute dulness indicates the edge of the lung, 
but not the size of the heart. Emphysema or 
pleural adhesions mask the true outline. A large 
heart and pericardial exudates displace the lung. 
whereas in emphysema, etc., the lung edge may be 
in a normal position or even cover an enlarged 
heart. Relative dulness when obtainable gives more 
accurate information, but must always be taken 
in conjunction with the superficial. Deep percussion 
begins at the lower border of the left third rib, and 
curves downward and outward to apex. To the right 
some authors give left para sternal Hue, but in mos: 
cases it goes to the right as far as the upper edge of 
the fourth rib at its sternal attachment. Over the 
sternum the lung gives a resonant note throughout 
and therefore renders percussion here uncertain. In 
old people, due to senile emphysema, the dull area is 
sm.all. In children, due to the thin edge of the lung, 
it is large. The shape of the thorax alters the relative 
position of the cardiac dulness, as a broad thorax does 
not give so large an area of dulness as a long narrow^ 
one. A narrow or displaced sternum may give the 
impression of a right heart enlargement. The centre 
of the clavicle, although the most reliable landmark 
for the mid-clavicular line, is not always reliable in 
localizing the heart, as the clavicle may not be sym- 
metrical in length, and even be longer or shorter, as 
compared to the breadth of the thorax. These varia- 
tions occur in narrow-shouldered, broad-chested indi- 



7f> NOTES OX PHYSICAL DIAGXOSIS 

viduals. In all such cases take the total breadth of 
the heart dulness at the third or fourth interspaces. 

Active and Passive Mobility of the Heart : In deep 
inspiration the area of superficial and deep dulness is 
diminished; the first ma}^ even be obliterated, while 
during deep expiration the areas are increased. 

With the patient in a recumbent position the heart 
is capable of lateral motion, especially to the right, 
which corresponds to the motion of the individual 
from side to side. Where absolute dulness can be ob- 
tained to the right of the sternum, with loss of flatness 
on the left, in the sitting position the dulness is 
slightly intensified. If the patient bends forward it is 
still more increased. This is due to the heart push- 
ing the lung to one side. Lateral inclination of the 
patient will falsify these results. 

Absence of Dulness: In emphysema, pneumo- 
thorax, pneumopericardium, and in heart atrophy, 
the dulness is too small to be appreciated. In high 
grade emphysema, the diaphragm is displaced down- 
ward, and therefore the heart is low. Pneumothorax 
also displaces the heart. Pericardial emphysema 
gives a metallic percussion note, and other ausculta- 
tory signs. If stomach tympany confuses the cardiac 
outline, bend the patient forward and use light per- 
cussion. 

Enlarged Heart due to a Retraction of the Lung: As 
from atelectasis, infiltrations, fibrosis, in the shallow 
breathing of weak people in whom the lungs retract; 
and in conditions diminishing the intrathoracic nega- 
tive pressure which act in the same way as pressure 
on diaphragm, etc. Infiltrations of the lung about 



METHODS OF PHYSICAL EXAMINATION 77 

the heart may stimulate cardiac enlargement. In en- 
largement of the heart the superficial and deep areas 
of dulness are not parallel. In extreme cases with 
very large hearts, there may be no demonstrable car- 
diac enlargement. Where the lungs are entirely 
pushed to one side, there is no deep dulness. \Mien 
compression of the lung exists, percussion does not 
indicate correctly the size of the heart. 

When percussion indicates an enlargement of the 
heart greater than one to two cm., dilatation is pres- 
ent, as the greatest hypertrophy without dilatation 
never exceeds one centimeter. 

Other signs show a pure hypertrophy better than 
the percussion, as, for example, a heaving apex, high 
tension pulse, accentuated aortic second sound, etc. 

One is tempted to say on obtaining dulness at the 
right of the sternum that the right heart is enlarged, 
or when the left cardiac area is by percussion mark- 
edly enlarged, that the left ventricle is enlarged. This 
is wrong, as a left or right heart enlargement can 
give an increased area of dulness upw^ards. This is 
due to the oblique position of the organ. An en- 
larged left ventricle can push the whole heart to the 
right. A right heart enlargement may be entirely to 
the left. Both cavities may be equally enlarged and 
the heart give a simple right or left heart enlarge- 
ment, all being due to the fact that a dilated cardiac 
cavity can lead secondarily to a displacement of the 
whole organ. The position of the enlarged heart is 
influenced by the condition of the contents of the 
mediastinum, by bony formation, the height or slant 
of the diaphragm, the attachment of the pericardium 



78 NOTES ON PHYSICAL DIAGNOSIS 

and great vessels and by pulmonary conditions. 
The right heart is difficult to percuss. It is covered 
by the sternum. Enlargement of the right ventri- 
cle tends to displace the heart to the left on account 
of the slant of the diaphragm. This is often seen in 
mitral disease with no enlargement of the heart to 
the right, but with an apex markedly displaced to the 
left. Enlargement upward, if conforming to the car- 
diac outline, is due to an enlargement of the right or 
left ventricle. If an absolute dulness is found near 
the base of the heart and close to the sternum, it may 
be due to an enlarged auricle, especially the left, or to 
the great vessels. In some cases, the dilated portion 
of the heart may push the lung absolutely to the 
side and give a pure flat note. This can be seen in 
markedly enlarged left auricles with a small ventricle, 
as in mitral stenosis. 

At times one can get a small process to the right 
of the sternum, due to an enlarged right auricle. 

Fluid in tlic Pericardium: The absolute (deep) and 
relative (superficial) areas of dulness are parallel, ex- 
cept in large exudates, in which there is absolute dul- 
ness only. As the specific gravity of the fluid is lighter 
than the heart, it rises and the heart sinks. In the 
recumbent position the fluid rises and gives a broad 
area. In the semi-recumbent position, there is a 
broad area of flatness above the normal cardiac area, 
due to the fluid rising above the great vessels and 
displacing the lung. The cardio-hepatic angle is 90 
degrees in the normal individual. In pericarditis, 
with effusion, it is an obtuse angle. In the erect 
position the lower diameter of flatness is broader 



METHODS OF PHYSICAL EXAMINATION 79 

from side to side than from above downward, as com- 
pared with the dorsal position. Care must be taken 
not to mistake an enlarged heart, that sinks on the 
diaphragm, due to its weight. Also in standing there 
is more blood in the peripheral circulation and the 
auricles are not so completely filled as in the lying- 
position. When pericardial adhesions exist, these 
rules do not hold. CEdema of the anterior media- 
stinum must not be mistaken for pericarditis with 
effusion. 

Displacement of the Heart: The heart is attached 
by the great vessels to the mediastinum above and 
lies in the pericardial sac attached to the diaphragm 
below. The organ floats in the thoracic cavity, and 
anything disturbing the equilibrium, such as changes 
of pressure above or below the diaphragm, or in the 
right or left pleural cavities, displaces the medi- 
astinum and thus changes the position of the heart. 
Displacements of the diaphragm do not occur 
acutely, as the fixation of the central tendon to the 
mediastinum is too strong. After a time this attach- 
ment yields and the central tendon descends. This 
is seen in mediastinal tumors, pleural exudates and 
emphysema. Upward displacements occur very 
acutely and are due to increased abdominal pressure, 
as from gas, ascites, tumors, etc. The displacement 
of the heart to the right or left is due to changes in 
the negative pressure of the two pleural cavities and 
exudate on one side diminishes the negative pressure, 
and there is displacement of the heart to the oppo- 
site side, due to an increased negative pressure of its 
pleural cavity. An enlarged left heart can diminish 



so XOTES ON PHYSICAL DIAGXOSIS 

the negative pressure in the left pleural cavity and 
thereb}' displace the heart to the right. Anything 
increasing the negative pressure on one side can draw 
on the heart, as is seen after pleurisies with dimin- 
ished volume of the lung, contracted pleura, fibroid 
phthisis, interstitial pneumonia, etc. In acute pleurisy 
with effusion,, the heart is displaced to the opposite 
side. After absorption, the heart is displaced to the 
diseased side, and after a time returns to its normal 
position if not bound by adhesion. Deformities of 
the thorax can displace the heart in any direction. 
Dextro-cardia must never be forgotten. In these dis- 
placements of the heart, the organ undergoes a pen- 
dulous movement. 

Auscultation. 

Auscultation of Heart Sounds: The Heart Tone 
is a misleading term, as it rarely yields a definite 
tone. Heart Sound is a better term. A s^-stolic 
and diastolic sound is spoken of. These sounds 
are compound. There are five systolic sounds: 
The mitral valve, tricuspid valve, beginning of the 
aortic and pulmonary, and the muscular sound. There 
are two diastolic sounds : The aortic and the pulmon- 
ary valve. The muscle sound must always be kept in 
mind. The heart muscle is not subject to tetanic con- 
traction as are the other muscles of the body. The 
heart muscle contracts suddenly with a correspond- 
ingly sudden vibration. As for the sounds produced in 
the big vessels at systole, these are not appreciated, as 
the first sound of the heart comes before the blood 



METHODS OF PHYSICAL EXAMINATION 8i 

gets into the vessels, and therefore before they vi- 
brate. The individual tones are difficult to distin- 
guish from one another, but as a general rule all im- 
purities of the first tone heard over the ventricle may 
be considered to emanate from the muscle. 

Anatomical Location of the Valves: The valves are 
anatomically too close together to differentiate the 
source of the sounds by auscultation when listening 
over this anatomical area. 

Clinical Location of the Valves: From clinical and 
post mortem observation classical points at which the 
valves' sounds are best heard have been determined. 

Determination of Systole and Diastole: At the base 
the second sound is usually louder than the first; at 
tlie apex, the first sound is usually louder than the 
second. The systolic interval is shorter than the dias- 
tolic. The sounds, however, may be identical at the 
places mentioned and the intervals may be of the 
same duration. This method is therefore not always 
to be relied upon. 

Palpating and observing the apex impulse unless 
absent is a good method. 

Palpation and observation of the carotids is relia- 
ble unless the heart is very rapid. 

The radial pulse occurs 22-100 of a second after the 
apex impulse, and is therefore uncertain, but unless 
the heart is rapid is for practical purposes reliable. 

The best guide is the accentuation of the sounds 
and the duration of the pauses. 

The Force of the Heart Tones: Factors outside of 
the heart itself which diminish the force, as fat, muscle. 



82 NOTES ON PHYSICAL DIAGNOSIS 

oedema of the thoracic wall, large breasts, pericardial 
and pleural effusions, emphysema, pneumothorax and 
any displacement of the heart as a whole. Heart tones 
are increased by thin chest wall, contraction of the 
lung, diminished negative pressure in the thorax as 
in kyphosis, high diaphragm, retractions of the lung, 
consolidations of the lung about or over the heart, 
displacements of the heart, pneumopericarditis, lung- 
cavities about the heart, pneumothorax and a dis- 
tended stomach. In these latter cases there is a 
metallic quality to the tones. Conditions zcifJiin the 
lieah itself: naturally strong heart, hypertrophy in 
compensation of organic diseases, varying quanti- 
ties of blood 'in the ventricles. Factors TchicJi -n'eaken 
the force of the heart: failing heart, as in collapse; 
lost compensation and valvular lesions. We may 
assume that the sounds in the right and left heart 
are heard on the chest wall with the same intensity, 
as the left ventricle is behind the right heart and the 
aorta is behind the sternum. The aortic second sound 
is intensified in high arterial tension and arterial 
sclerosis. The pulmonic second sound is increased in 
mitral disease, a feeble left ventricle and in pulmonary 
conditions. \Mien compensation fails, the sounds are 
weak or absent. In hypertrophy the first sound is 
not necessarily increased, as this is more dependent 
upon the rapidity than upon the amount of the con- 
traction. When we have a low tension in the arteries 
we get a loud sound as the heart contracts with vio- 
lence ; with high tension the sound is weak, due to the 
slow^ contraction ; also a complete filling of the ventri- 
cle causes the valves to be put on a slight tension be- 



METHODS OF PHYSICAL EXAMINATION 83 

fore systole, which lessens the mtensity of the first 
sound. This is heard in mitral regurgitation and in 
prolonged diastole. Changes in the valves produce 
diminution in the intensity of the heart sounds, but 
this is not always the case, as, for instance, increase 
in the intensity of the heart sounds may be heard in 
diseases of the aortic valve. Absence of the sounds 
suggests organic disease, but is not diagnostic. In 
mitral regurgitation, there is no left heart sound, 
as the closure period is absent. There is more blood 
in the ventricle, therefore a slower contraction, and 
the aorta is not put in vibration as less blood flows 
into it. The aortic sound may be weak, because there 
is less tension in the vessels and also more blood 
comes from the auricle, thus more nearly equalizing 
the tension in the ventricle and aorta. Insufficiency of 
the mitral and tricuspid valves occasionally leads to a 
total absence of the first sound. The diminution of 
the right or left heart sound gives some idea of the 
extent of the insufficiency, provided compensation is 
complete, as this will cause weakness of the sound. 

The Quality of the Heart Sounds: Varies greatly in 
the normal heart. May be sharp and ringing, low 
and dull, or rough. Pathologically: A loud ringing 
second aortic is heard in atheroma ; a ringing first in 
aortic dilatation and aneurism, nervous palpitation, 
and in hypertrophy. Impureness or roughness of 
the first sound may be due to poor closure of a nor- 
mal valve, to a stiiT valve, or to sHght insufficiency; is 
also heard in chronic myocarditis.'^' 

* Roughened aorta from atheroma is an important and common 
factor producing a systolic murmur or roughening at the aortic area. — 
Editor. 



§4 XOTES ON PHYSICAL DIAGNOSIS 

Increase in Number of Sounds: The sounds are nor- 
mal in character, but the events in the cardiac cycle 
do not occur with the normal synchronism or extra 
sounds are added. ^ Divided or split sounds are 
those in which there is a double sound heard, with 
a very slight interval. Double or re-duplicated 
sounds are those in which a more pronounced inter- 
val occurs. The re-duplication of a sound may be due 
to nervous disturbances or variations in pressure. 
Re-duplication of the second sound is thought to be 
due to high tension, closure of one valve (that un- 
der the highest pressure) before the other. Sahli 
denies this and says it is due to a difference of pres- 
sure within the arteries and ventricles, that is, when 
the pressure in the ventricles is very low, closure of 
the arterial valves occurs more rapidly. Sometimes, 
in normal breathing, during inspiration, the blood 
does not flow into the left ventricle as rapidty as into 
the right ; therefore the pressure in the right ventri- 
cle is low and the aortic valve closes before the pul- 
monic. This is normal re-duplication. The same oc- 
curs in mitral stenosis for a similar reason; the aortic 
valves close first. In mitral regurgitation the case is 
different, as the increased quantity of blood thrown 
into the ventricle equalizes the pressure between the 
aorta and the left heart; therefore the aortic closes 

* It must be remembered that the two normal heart sounds are com- 
posed of many sounds. The occu?rence of but two sounds depends upon 
the perfect synchronism of all the events going to make up these sounds. 
Anything which disturbs this sequence will delay one or the other of the 
factors producing the sounds, and the belated event will be evidenced by 
an additional sound. These extra sounds are verj^ important clinical 
evidences of disturbed cardiac mechanism and should be carefull\' stud- 
ied bv the clinician. — Editor. 



METHODS OF PHYSICAL EXAMiyATIOX 85 

slower and the pulmonic faster, or first. In support 
of this theory he states that the second sound does 
not come with the actual closure of the semi-lunar 
valves, but is due to tension in the arteries after these 
valves are closed. In utilizing this re-dtipHcation of 
the second sound for diagnosis, it must be constant 
and not restricted to any phase of respiration. Re- 
duplication of the first sound is heard over the vessels, 
and is due to some difference in the tension of the 
valves. This can be brought about in conditions 
where the tension being high in the arteries the 
closure period is longer, therefore a normal but de- 
layed sound is produced. The second portion of the 
re-duplication, being due to the tension in the large 
vessels, is heard at the base of the heart more dis- 
tinctly than normally. Physiologically this can be 
produced by slow, deep breathing, as this act raises 
the arterial pressure. 

Triple RhytJini: In mitral stenosis this rhythm is 
heard at the apex. The murmur may or may not be 
present. It is produced in the mitral opening, as it 
is best heard at the mitral area. It is due to the con- 
tracted valve forming a diaphragm, against which 
blood is thrown by the large hypertrophied auricle. 
It must not be confused with reduplicated second 
sounds. The rhythm is different, as is also the loca- 
tion. 

Gallop Rhythin : Three sounds are heard over the 
whole of the heart. At the apex the middle sound is 
accentuated; at the base the last. This differs from 
that just described in that it is heard over the w'hole 
heart area. It is caused bv the sudden relaxation of 



86 NOTES OX PHYSICAL DIAGXOSIS 

the ventricular wall, the blood being thrown into the 
ventricle at the auricular contraction. 

To recapitulate, then, we have the following: Re- 
duplication of the first tone is heard at the base, due 
to the unequal tension in the ventricle and vessels ; 
doubling of the first tone is heard at the apex in 
mitral stenosis; doubling of the first tone is due to 
the diastolic tension, and heard over the whole heart. 
Doubling of the second tone is due to alterations be- 
tween the great vessels and the respective ventricles. 

Auscultation of the Heart Murmurs : The name tone 
applies better to murmurs, as they are more often 
of a musical tone than the heart sound itself. The 
sounds in the heart and vessels are produced by a 
single vibration transmitted to a substance. Mur- 
murs are a number of such vibrations. A tone can 
be compared to a blow on a drum, a murmur to that 
of a sound produced by blowing through a tube. 
Alurmurs can be endocardial or pericardial, or acci- 
dental and pneumo-pericardial. Alurmurs heard by 
patients themselves or at a distance are usually musi- 
cal. Two factors enter into the production of mur- 
murs : the force and rapidity of the stream and the 
changes in the calibre of the valve chamber or vessel 
through which the stream is flowing. 

Valvular Murmurs: Murmurs are produced by the 
blood passing from the normal heart calibre through 
a narrow opening. The blood may flow in the normal 
direction, but through a narrower calibre, as in sten- 
osis. The blood may flow in an opposite direction to 
that of normal, the valve not closing sufficiently. In- 
sufficiency takes place by a shortening of the valve in 



METHODS OF PHYSICAL EXAMINATION 87 

its long diameter, by holes or tumors, by excrescences 
or thickenings preventing close opposition of the op- 
posed surfaces. Relative insufficiency takes place by 
an enlargement of the ventricular cavity, displacing 
the papillary muscles, and thus preventing the valves 
from closing, also by too strong a diastoHc filling of 
the ventricle, either through a too great supply of 
blood from the veins, as in non-compensating heart, 
or from blood being left behind, as in failing heart. 
Functional insufficiency of the auricular openings is 
seen in nervous disturbances and in improper inerva- 
tion of the papillary muscles. Relative insufficiency 
of the vascular openings may be due to dilatation of 
the ring from high pressure or diseases of the arterial 
wall. Never forget that the murmurs are dependent 
for their production upon the celerity of the blood 
stream. Their lack of production is especially seen 
in mitral stenosis and in aortic insufficiency, with 
mitral and tricuspid regurgitation, the tension being 
too low in the arteries to produce a murmur. The 
quality of the murmur has no clinical value, as it is 
dependent more upon the shape than the degree of 
the opening. Loud murmurs are heard with medium 
sized openings ; small or large openings cause weaker 
murmurs. This is of no value, as there is no unit by 
which to compare loud and soft murmurs. In feeble 
heart action the murmurs may be weak or absent, 
and only by exercising the patient or awaiting com- 
pensation can the murmur be heard. In listening 
to the heart in the standing or lying position, the 
murmurs vary greatly, due to changes in the blood 
pressure. In mitral stenosis in the dorsal position 



88 NOTES ON PHYSICAL DIAGNOSIS 

at times no murmur can be heard. This is in some 
cases true also of aortic insufficiency. In this latter 
condition, if the patient assume the erect position, 
gravity increases the celerity of the blood and so 
emphasizes the murmur. In aortic stenosis the mur- 
mur in the upright position may disappear entirely. 
Accidental or relative murmurs usually have a softer 
character than the organic. However, this does not 
apply to all cases, as some accidental murmurs are 
very rough and loud, while organic murmurs may be 
of a very soft character. 

Note. — These variations in quality and intensity of murmurs, with 
changes of position, are more usually associated with functional than 
with organic murmurs. — Editor. 

Localization of Murmurs'. Classical points for the 
valves : Apex for mitral, lower portion of sternum 
for tricuspid, right and left second interspaces for 
aortic and pulmonary. Murmurs are produced on 
both sides of the lesion, and the side with the wildest 
cavity produces the loudest vibration. The nearness 
of the lesion to the surface and the condition of the 
organs under and overlying same are factors influ- 
encing the location of maximum intensity of mur- 
murs. The column of blood is not only a conductor 
of sound, but as the sound is produced on one or the 
other side of the opening through which the blood 
tlows, this causes some murmurs to be loud and 
others soft. Sounds travel better with the current 
of the blood than against it.* Systolic murmurs pro- 

* Time of AlMrmtirs. The pulse at the wrist, the vessels of the 
neck and the apex beat must always be observed in determining the 
time of the murmur. This is essential, as even practised ears cannot in 
many instances determine the time of the sounds on listening alone. — 
Editor. 



METHODS OF PHYSICAL EXAMINATION 89 

dnced by aortic stenosis are transmitted to the neck 
and are heard best over the second interspace. At 
times this murmur may be heard over the ventricle 
or even at the apex. This is due to the fact that the 
murmur is produced in the ventricle and not in the 
aorta." 

Diastolic aortic munnurs are heard best over the 
third left rib, over the ventricle or apex. This is due 
to the fact that the murmur is produced in the ventri- 
cle, the blood flows towards the apex and that the 
aortic valve, at the second right interspace, is deeply 
situated. In exceptional cases the murmur is heard 
in the vessels of the neck alone. 

Systolic munnurs of the mitral valve are heard best 
at the apex, where the first sound is produced. The 
left ventricle comes to the surface at this point alone. 
The murmur is louder in the large cavity of the ven- 
tricle than that of the auricle, although the blood 
flows away from the apex. When the auricle is mark- 
edly dilated, one can hear the diastolic murmur over 
the second left interspace. This is due to the wide 
cavity of the auricle, the direction of the blood 
stream, and displaced lung. A markedly dilated ven- 
tricle by displacing the lung can approach the chest 
wall, and the murmur be heard best over the third 
left interspace. 

Diastolic mitral murmurs are heard best at the apex 
and are very local, because the blood flows towards 
the apex. The ventricle is the larger cavity, and the 

* Remember that in speaking of a murmur as being " heard at'' cer- 
tain points, the locality referred to always means the area of " niaxiiniim 
intensity " of the loudness of the murmur. — Editor. 



90 NOTES OX PHYSICAL DIAGNOSIS 

the apex lies against the thoracic wall. In very large 
right hearts in mitral stenosis the left ventricle can 
be covered by the right and the murmur may be ab- 
sent. True diastolic murmurs coming at the begin- 
ning of diastole are found in cases of very large auri- 
cle with small ventricle. The murmurs are heard 
over the auricles. 

Systolic friatspid munnurs are best heard at the 
lower part of the sternum and at the right of the same, 
as the right ventricle and auricle lie closest to the 
thoracic wall at this point. This is more distinct the 
greater the dilatation of the auricle and ventricle. 

Diastolic tricuspid inunniirs are heard best over the 
.same point. 

Systolic pulmonary munnurs are heard best over 
the pulmonary area and over the whole of the right 
ventricle. This murmur is heard under the left 
clavicle and distinctly behind, and is not heard in the 
vessels of the neck. 

Diastolic pulmonic murmurs are heard over the 
lower part of the sternum on account of the direc- 
tion of the blood flow and the size of the ventricle. 
They are never heard in the vessels of the neck. 

The above rules apply only when the heart is not 
essentially changed in size and position. The heart 
sounds associated with murmurs are produced in the 
heart wall, in the big vessels and from the normal 
valves. The intensity of the murmur is dependent on 
the celerity of the blood stream. Therefore, most 
murmurs diminish in intensity as agents acting upon 
the blood stream, the heart muscle, for example, fail. 
Only in the auriculo-ventricular stenosis is this rule 



METHODS OF PHYSICAL EXAMINATION 91 

reversed, as in the auricular contraction the celerity 
of the blood is increased toward the end of the pause. 
This is the only characteristic murmur, and even in 
rapidly beating hearts the phase of the heart cycle 
may be determined by this murmur. 

Exceptions to the Presystolic Mitral Murmur: At 
times it is a true diastolic murmur heard at the be- 
ginning of diastole and best heard over the base of 
the heart. The next form of this murmur is when we 
have a true diastolic dying away and then followed 
by a presystolic. This is brought about by the dam- 
ming back process and the added auricular contrac- 
tion. This is seen in moderate lesions. The next 
is the true short presystolic murmur heard only at 
the apex in advanced stenosis, when the blood flows 
through the opening so slowly in the beginning of 
diastole that there is no murmur produced till the 
auricle contracts. When the auricle is unable to con- 
tract, as in the most marked forms of this lesion, there 
is no murmur heard at all.* A prediastolic murmur 
heard just before the second sound as a rule means a 
slight mitral or tricuspid insufficiency, as it comes at 
the period when the pressure in the ventricles is high 
and is produced by a slight giving way of the ring or 
papillary muscles. It is also favored by the fact 
that the auricle is completely dilated at this period 
by the sHght leak and gives a larger cavity for the 

* Two-thirds of the auricular contraction is passive (non-muscular), 
one-third is active (muscular), this last one-third is what is spoken of as 
"Auricular Systole," It is during this last one-third that a presystolic 
murmur is produced by the effort of the heart muscle to force the blood 
out of the auricle through the stenosed (narrowed) mitral orifice. — 



92 NOTES ON PHYSICAL DIAGNOSIS 

production of the murmur. This must not be con- 
fused with pauses between the closure time, first 
sound, and the systoHc murmur in aortic and pul- 
monary stenosis. This is so very short that there 
should be no cause for confusion. 

Double Lesions: Systolic murmurs heard at the 
apex and over the aorta : The murmurs may be of a 
different character and strength at the two places. 
This is a dangerous criterion, as the transmission 
may alter the character and strength greatly, as a 
loud mitral or a weak aortic may have exactly oppo- 
site significance. At both points the murmur may 
be of equal quality and strength. By moving the 
stethoscope from one point to another these varia- 
tions in the intensity of the murmur may be detected. 
This is only valuable when the difference in dura- 
tion, intensities of the sounds, character and phase 
of the murmur are noted. There are many condi- 
tions modifying the murmur, as the right ventricle, 
lung, etc. Keep in mind that the classical points 
for the auscultation of murmurs do not hold good 
on changes in the size and position of the heart and 
surrounding organs. The murmur alone is not suffi- 
cient to diagnose a heart lesion, as will be repeatedly 
proven at the autopsy table. 

Accidental Murmurs: The relative murmurs are 
the same as the organic, as far as the physical signs 
go, and therefore must be classed with the organic 
till excluded by treatment, rest, etc. 

Haemic is a misleading term for certain functional 
niunnurs, as a great majority of these murmurs have 
nothing to do with the condition of the blood. Ac- 



METHODS OF PHYSICAL EXAMINATION 93 

cidental murmurs are mostly systolic and are heard 
usually over the apex and the pulmonary area. As 
these often have the same character as the organic, 
they may be considered as being produced by the 
blood stream, and following the same laws. It is 
strange that the normal heart produces no murmurs, 
and that these adventitious sounds are limited to 
pathological conditions. Marked variations in the 
calibre of the heart cavities fit exactly to the laws that 
we apply to the production of murmurs. This may 
be explained by the fact that there is no suitable 
relation between the variations in calibre and the 
celerity of the flow of the blood. It has been defin- 
itely proven that the blood can flow out of the nor- 
mal heart 16^2 times faster than it ordinarily does, 
and that the ventricles are more distended during 
diastole in the slow beating heart. All these points 
go to make up conditions favoring the theory of the 
production of murmurs. The conditions, however, 
are not the same in the diastolic accidental murmurs, 
as there is nothing to vary the force of the contrac- 
tion, the quantity of the blood, and the configuration 
of the heart. This latter is well seen in mitral steno- 
sis with the frequent absence of the murmur, as the 
low arterial blood pressure favors quick ventricular 
contraction. Sahli, however, thinks that the blood 
pressure has little influence. Fever and weakness 
favor low blood pressure and quick ventricular con- 
traction. In anaemia the diminished cohesion of the 
blood favors the production of murmurs, as it has 
been shown that the blood flows faster in anaemic 
people than in normal. The venous hum is by some 



94 NOTES OX PHYSICAL DIAGNOSIS 

explained in this way. The systoHc murmurs produced 
by roughness in the aorta or endocardium, due to 
atheroma, are of course not to be classed among 
functional or accidental murmurs. The pulmonary 
artery, rarely, if ever, becomes atheromatous. Ac- 
cidental murmurs may be systolic respiratory mur- 
murs. 

Diastolic accidental murmurs are heard over the 
aorta and are confused with true insufficiency. The 
point of differentiation is that the diastolic functional 
murmur increases in intensity as one passes to the 
vessels of the neck. A diastolic murmur heard all 
over the cardiac area is usually due to marked 
anaemia, and is found where the haemoglobin is very 
low, 15 to 25 per cent.* Some murmurs are un- 
explainable and may be associated with any lesion. 
In making a diagnosis, use every means to exclude 
a true lesion, then take up the conditions causing 
accidental murmurs ; even then a positive opinion 
cannot be formed. Don't forget that in anaemia rela- 
tive murmurs are frequent, also in atheromatous con- 
ditions of the aorta murmurs are frequently heard 
over the aorta and apex. Diastolic accidental mur- 
murs are only heard in severe anaemias, and are al- 
ways accompanied by systolic murmurs and venous 
hums. The character of the murmurs means nothing, 
as accidental murmurs may be very loud and the or- 
ganic very faint. Prediastolic murmurs are never ac- 

* Research has definitely proven that the blood condition cannot be, 
even within v^^ide limits, determined from a functional murmur. The 
murmur is frequently marked when the blood is normal, and vice versa. 
The blood and heart should always be thoroughly studied quite inde- 
pendently of one another. — Editor. 



METHODS OF PHYSICAL EXAMINATION 95 

cidental. The influence of respiration on organic and 
accidental murmurs is marked. This is due to the 
covering of the heart with the lung or variations in 
the blood stream due to respiration. In inspiration 
the lung covers the heart, and the murmurs are 
fainter; in expiration the reverse is the case. The 
flow of blood in and out of the right heart is favored 
by inspiration. By quick inspiration the vessels in 
the lungs are dilated and the blood is held back from 
the left ventricle. In slow, deep breathing this hap- 
pens only at the first part of inspiration. 

Pericardial Miinnurs: Are all those heard syn- 
chronously with the heart action, but produced out- 
side of the heart cavities. 

Pericardial rubbing. 

Pleuro-pericardial rubbing. 

Precordial emphysema. 

Pericardial splashing. 

Pericardial rubbing is due to inflammation, depos- 
its, tuberculosis, tumors, or abnormal dryness of the 
pericardial surfaces. The murmur may be loud and 
rough or soft, the latter easily being confused with an 
endocardial murmur. Also rough endocardial mur- 
murs may be mistaken for pericardial friction rtib. 
The endocardial murmurs are more closely associated 
with the heart sound, though this is by no means con- 
stant. The pericardial murmurs come at any time, 
between the heart sounds, overlapping same, or may 
be a continuous murmur, without relation to the 
heart sounds. The beginning of the pericardial 
murmur comes before the first sound, and is due to 
the fact that the outer wall of the heart during the 



96 NOTES ON PHYSICAL DIAGNOSIS 

first part of the propulsion time moves before the 
full ventricular contraction begins. Murmurs may 
come in the middle of systole and diastole with dis- 
tinct pauses between the sounds. They may begin 
in the middle of systole and terminate in the middle 
of diastole. They may be continuous, increasing in 
intensity at the middle of systole and diastole. As the 
murmur is produced on the anterior portion of the 
heart, it is best heard when the lung is thin or absent. 
If pericarditis is of the adhesive variety, or if fluid is 
present, the murmur may come and go as conditions 
allow. Even when fluid is present, the murmur can 
be heard at the base where the surfaces are close to- 
gether, or at the apex where the weight of the heart 
brings the surfaces in contact. By bending the pa- 
tient, forward pericardial murmurs are increased, 
whereas endocardial murmurs are changed by the 
recumbent or erect positions. In deep inspiration 
the lung presses on the pericardium and increases 
the murmur. 

The respiratory phase in varying the filling of the 
right and left ventricles influences the murmur. Val- 
salva's experiment of deep inspiration with the reten- 
tion of the breath and straining, as at stool, keeps 
the blood from the thorax and the heart. Under 
these conditions the endocardial murmurs decrease 
in intensity. The pericardial by pressure of the lung 
increase. This is a dangerous procedure. 

Pleiiro-pericardial Murmurs between the Heart and 
the Costal Pleura or the Heart and the Lung Pleura: 
Pericardial murmurs are heard where the heart lies 
bare, as near the sternum ; extra pericardial near the 
outer edge of the true cardiac flatness. 



METHODS OF PHYSICAL EXAMINATION 97 

In pericardial emphysema with air in the anterior 
mediastinum, there is absence of the heart duhiess 
and a feebleness of the heart sounds, and with each 
contraction of the heart, crepitant rales of a metallic 
quality are produced. The pericardial splash with 
a metallic sound is heard synchronous with the heart 
sounds, and must be differentiated with that produced 
by the stomach and pneumothorax. 

This can be done by exclusion and by percussing 
the heart, wdth changes in position of patient. The 
heart sounds may themselves have a metallic quality. 

Auscultation of the Vessels: Aside from those trans- 
mitted from the heart, the vessels are, by the same 
laws, capable of producing sounds and murmurs. 

Auscultation of Arteries: Listen over the carotids, 
the subclavian, and above and below the clavicle, over 
the radials, the crural and the abdominal aorta. On 
auscultating over the carotid or the subclavian, a sys- 
tolic and a diastolic sound can be heard from the 
heart. The brachial, the crural and the abdominal 
aorta may give a systolic sound. The smaller ar- 
teries give no sound. By pressing the stethoscope 
on a vessel a systolic murmur is heard. If the vessel 
is obliterated a systolic pressure sound is produced. 
In children from three months to six years old, a 
systolic murmur is heard over the fontanelles and 
head. This is physiological, and is principally pro- 
duced in the carotids. As the heart sounds both nor- 
mally and pathologically are transmitted into the 
carotids and subclavians, an absence of the second 
sound suggests aortic insufficiency. In pulsus celer 
from fever or aortic insuf^ficiency, a tone is heard in 
7 



98 NOTES ON PHYSICAL DIAGNOSIS 

all the arteries, small and large. In marked aortic 
insufficiency, a double sound can be heard, due to the 
relaxation of the arteries. This is at times also heard 
in chlorosis, pregnancy and lead poisoning. In aortic 
insufficiency, by placing the stethoscope on one of the 
large arteries, one or two sounds are heard. 

Subclavicular Murmurs: By auscultation of the 
subclavian artery with the arm hanging by the side, 
in cases of tubercular disease of the apex with adhe- 
sions, a murmur can be heard, increased on deep in- 
spiration and sometimes on expiration. Care must be 
used that the inspiratory act does not increase the 
pressure of the stethoscope on the arteries. This 
has little value, as it is heard in normal individuals 
with varying position of the arm. Over the carotids 
can be heard murmurs analogous to that heard in 
anaemia, but differing from the venous murmur. This 
can be heard over the aorta and the carotids and can 
even be palpated. Over the facial vessels of those 
with Basedow's disease a systolic murmur can some- 
times be heard. 

Auscultation of the Veins: Normally the blood 
flows through the veins without any murmur or tone. 
In exceptional cases there is a slight hum. In tri- 
cuspid regurgitation by tension on the veins and 
closure of the valves in the bulb, a loud systolic tone 
can be heard, distinguishable from the carotid in that 
it precedes it. 

Tlic Humming Murmurs: 

One hears a continuous murmur with a systole and 
sometimes with diastole over the vessels of the neck, 
which is increased in intensity during inspiration. 



^v ^^ 



METHODS OF PHYSICAL EXAMINATION 99 

The point to auscultate is the attachment of the 
sterno-mastoid muscle to the thorax. 

It is heard best on the right side, as the flow of 
blood is more direct to the heart. 

In the upright position the flow of the blood is ac- 
celerated in the veins from the head, so that one 
hears this murmur better in the erect position. 

In the dorsal position the murmur is usually lost. 
By turning the head to the left or by slight pressure 
of the stethoscope the murmur is increased. 

As the flow in the veins is continuous, the murmur 
that is heard is usually constant. 

These interrupted murmurs may be confused with 
the cardiac, arterial, or respiratory sounds. Only 
by noting the point of maximum intensity and the 
variations in character in the different positions of 
the patient can the diagnosis be made. 

The Cause: It is not due to a collapse of the veins, 
as this does not take place where the murmur is 
heard. The following theories have been advanced: 
(i) the increase of celerity with which the blood flows 
in anaemic conditions; (2) the passage of the blood 
from the veins into the bulb ; (3) a diminished co- 
hesion of the blood. When heard in normal indi- 
viduals, it may be due to some anatomical anomaly, 
or to variations in the celerity of the blood flow. In 
the standing position, the sucking action of the res- 
piration increases the velocity of the blood flow and 
gives all the conditions for the production of mur- 
murs at the bulb. Turning the head to the left may 
cause some constriction of the veins by the sterno- 
mastoid or omohyoid muscles. Systole increases the 



lOo NOTES ON PHYSICAL DIAGNOSIS 

murmur, as in the venous pulse at this time the curve 
is an ascending one. The increase during diastole is 
more complicated. It may be due to a vibration in 
the walls of the veins caused by the normal ascent 
of the negative pulse wave. The same murmur can 
be heard over the crural veins at times and also over 
a vascular goitre or tumor. Sahli thinks that they 
are of value if marked. In Basedow's disease, the 
hum heard over the veins may be transmitted from 
the goitre. 

Note. — Cardio-Respiratory Mtirmur : This is not produced in the 
heart or vessels, but is due to the forcing out of the air from the air cells 
of the lung by the heart with each contraction squeezing the lung against 
the thoracic wall over the proecordiam. The murmur has a " puffing" 
quality, is loudest on inspiration and disappears on expiration. 

The Uterine Bruit: Loud systolic murmur similar to that heard over 
a vascular goitre is heard normally over the gravid uterus, and, like the 
former, is due to the tortuous and numerous blood vessels. 

Mediastinal adhesions may produce both friction rubs and sounds 
resembling murmurs. The mediastinum as the seat of enlarged glands, 
tumors and inflammation must not be forgotten. This important space 
is receiving more attention clinically of late. 
General Classif cation of JMnrmurs : 

Organic — Actual cardiac lesion; diseases of valves, etc. 
Functional — No cardiac lesion, anaemia; cachexia, etc. 
Mechanical — No lesions, cardiac or otherwise; cardio-respiratorv. 
Accidental — Adhesions pulling upon the heart or blood vessels; 
Subclavian (systolic) — Editor. 

The Pulse. 

The character of the pulse is an indication of the 
heart strength, the blood pressure, and the condition 
of the peripheral arteries; valvular lesions, fever and 
certain cardiac neuroses also have certain pulse char- 
acteristics. 



METHODS OF PHYSICAL EXAMIXATIOX lOi 

Tlic Methods: Finger, sphygmograph, sphygmom- 
eter, inspection and auscultation. 

Palpate the radial artery over the styloid process 
of the radius between the tendons of the supinator 
longus and the radialus internus. Keep in mind that 
this is not a constant position. Always compare both 
radials as to size, as they vary greatly in normal 
individuals. Use the larger of the two for diagnosis. 

TJic Arterial J Fall: Try to roll the artery under 
the finger, note hardness and resistance as the con- 
dition of the arterial wall influences the pulse \vave 
markedly and must be first determined. In the high 
grades of arterial thickenings the vessels are tortuous. 
This is a normal condition for the temporals, but they 
are not nonnally z'isiblc. Deposits of chalk in the 
vessel wall may be felt. A high grade of local arterio- 
sclerosis of the aorta, of the vessels of the kidneys or 
of the cerebral vessels may exist without change in 
the peripheral arteries. In these cases a hard pulse 
is usually found and some changes in the urine. In 
counting the pulse beats, if irregular, count one min- 
ute and repeat, taking the highest count. The pulse 
varies physiologically. Psychical influences, espe- 
cially in nervous people, cause marked variation in 
pulse rate. The pulse rate rises during motion and 
change of position of body after which it soon falls. 
This is true also during and after the passage of 
urine and faeces. After exhaustion the pulse remains 
high for some time. 

Rate: In the recumbent position 66, in the sit- 
ting 71, in the standing 81. The taking of food in- 
creases the pulse rate, especially after a heavy meal. 



I02 NOTES ON PHYSICAL DIAGNOSIS 

when this mcrease may persist for some hours. Daily 
variations are due to food or starvation, in the latter 
the variations being probably caused by changes in 
the bodily temperature. 

TJie Influence of the Blood Pressure: When the 
blood pressure is high the pulse is slow, when low 
the pulse is accelerated. In the recumbent position 
the blood pressure is higher than in the erect. In- 
spiration and coughing increase, expiration decreases 
the blood pressure. 

Variations as to Age: In the foetus 133 to 144; in 
the first year 123 to 143; ten to fifteen years 76 to 
91 ; twenty to sixty years 69 to 83. After the age 
of sixty, it progressively decreases. Women have 
from seven to eight beats more than men of the same 
age and size. Tall people have a lower pulse rate 
than short people. When the pulse is not felt with 
an apex beat, it may be due to a hemi-systole. The 
fever and the pulse curve run about parallel. Each 
degree of temperature equals about eight pulse beats. 
A hig-h pulse rate and a low fever means a grave 
prognosis, as it indicates a disturbance of the cardiac 
or vasomotor apparatus. A high temperature w^ith 
a low pulse rate is seen in patients with cerebral 
pressure, diseases of the myocardium, tuberculous 
disease. A high pulse with a low temperature is seen 
in collapse. In typhoid fever the pulse is low in com- 
parison with the fever. This is a point against miliary 
tuberculosis and sepsis. In pulmonary tuberculosis 
and in children the pulse rate is very high, in com- 
parison with the temperature. Diseases of the heart, 
lost compensation, endo- and pericarditis, Basedow's 



METHODS OF PHYSICAL EXAMINATION 103 

disease, nervous tachycardia, pressure on the heart, all 
cause a high pulse rate. Pain may increase or de- 
crease the pulse rate. Certain drugs increase, others 
decrease, the rate and pressure. This influence of 
drugs must be taken into account, in interpreting 
the pulse. Psychological influences must be consid- 
ered in palpitation and subjective dyspnoea. Lozv 
pulse rate: Normal in some people; as low as 20 in 
fatty heart ; slightly slowed in aortic insufficiency and 
cachexia; after the crisis in fever and during conval- 
escence ; in pain and shock, and jaundice. During 
the onset of the jaundice the pulse is slow; later, by 
the heart adapting itself or due to elimination of bile 
acids by other channels, the pulse becomes normal. 
In all these cases there is a marked tendency to an 
increase in the pulse rate from slight causes. The 

Relation of pulse, temperature, and respiration. 

72 98! 18 

Respiration to pulse, i to 4. Temperature to pulse, 1° to 10 beats. 

—Editor. 

drawing off of fluid from the chest or abdomen slows 
the pulse. A physiologically irregular pulse is rare, 
but is very frequent as a transitional condition and is 
associated with conditions which influence the rate. 
Marked disturbance suggests an organic disturbance 
of the heart. Usually an arrhythmic pulse is accom- 
panied by irregularity in force. In speaking of the size 
of the pulse, the degree of distension of the arterial 
wall is meant. A celer pulse is a sudden rise and fall of 
the pulse wave, as seen in aortic insufficiency and in 
all conditions lowering the arterial tension. Tardus is 
a slow wave as in aortic stenosis. There are many 



I04 XOTES ON PHYSICAL DIAGXOSIS 

combinations of these two. The word celer should 
be applied to the water hammer pulse, as tliere are 
many forms of sudden rise with slow descent which 
may be considered as true pulsus tardus. In feeble 
hearts the celer pulse disappears. 

Tension: As a rule, with the celer pulse the blood 
pressure is below normal; conversely, a small pulse 
can be easily obliterated and yet the blood pressure 
be very high. Try to determine the tension between 
the systoles. A high tension pulse must not be 
confused with thick arterial walls. In fever the blood 
pressure during the systole is high, during diastole 
it is low. A dicrotic pulse is seen in all conditions of 
low tension, and is best appreciated by Hght palpa- 
tion. With sloAv, deep respiration the pressure in- 
creases, and the size of the pulse decreases during 
inspiration; during expiration the opposite obtains. 

Capillary Pulse: Pressing lightly on the patient's 
finger nail or drawing one's finger nail across the 
patient's forehead shows a pulsating blush at the 
junction of the red and white areas. This is capillary 
pulse. It is not seen in healthy individuals. With 
low arterial tension and in the celer pulse, as in Base- 
dow's disease, fever, chlorosis, etc., the capillary pulse 
may be seen, but this is by no means always true. It 
is also seen in aortic insufficiency in the compensating 
stage and in areas of inflammation. It is caused by 
anything which facilitates the flow of blood in the 
capillaries or retards the outward flow from the same. 
The normal pulse wave is lost in the arterioles or 
else recoils. 

TJie Effect of Respiration on the Veins: In inspira- 



METHODS OF PHYSICAL EXAMINATION 105 

tion they collapse, in expiration they fill. This is seen 
not in normal but in forced breathing. If venous 
congestion is present this phenomenon is seen with 
the normal respiration. When the patient coughs 
dilatation of the cervical veins is distinctly seen, and 
in conditions of chronic violent coughing a perma- 
nent venous dilatation may result. Dilatation of the 
veins by inspiration is seen in chronic mediastinitis, 
due to the pull of the lung on the vessels ; also where 
some pressure is exerted on the vessels, as in peri- 
carditis with effusion, pleural effusions and media- 
stinal tumors. This latter may inhibit the movement 
of the thoracic contents, and thus be a factor influ- 
encing the flow of blood in the veins. 

Venous Pulse: Can be distinguished from the arte- 
rial by its large, flat, undulating movement, in con- 
trast to the sudden impulse of that of the artery. It 
has little force or tension. By compressing above it 
disappears. By pressing below it is increased. This 
last does not apply if the pulse is positive (i.e., due 
to tricuspid regurgitation with true cardiac impulse). 
The normal negative pulse is not seen in those with 
indistinct jugular veins, and is intensified in those 
with slight disturbances of the circulation. In posi- 
tive venous pulsation, compression of the vessel 
causes the pulse to disappear above the point of com- 
pression. In negative venous pulsation the pulse dim- 
inishes or disappears below the point of compression. 
\Mien negative pulse persists below the point of com- 
pression, it is due to a large vessel emptying into the 
jugular below this point. If pulsation is marked 
above the point of compression the pulsation is due 



io6 NOTES ON PHYSICAL DIAGNOSIS 

to a transmission from the arteries or to an arterio- 
venous communication. The valves of the jugular 
vein do not retard the negative pulse, as it is a wave 
and not a regurgitation. 

Venous collapse occurs with the first part of systole 
and is due to the dilatation of the auricle, and the 
sucking action of the systole of the heart. The dila- 
tation of the veins is due to four factors, one working 
against three. This one against the three is the suck- 
ing action of the dilated ventricle. The three factors 
which favor dilatation of the veins are (i) the increased 
thoracic pressure of the dilated heart ; (2) the closure 
time before systole; (3) the auricular contraction. 
The cause of the wave in the middle of the ascending 
Hmb of the venous curve is due to the stopping of 
the blood as the auricle is filled and starts to contract. 
This causes a sudden stop of the blood flow into the 
auricle and causes the wave. In comparing the nega- 
tive venous pulse with the positive, never judge by the 
apex beat, as the apex impulse occurs with the closure 
time, and therefore with the height of the negative 
venous pulse wave, and would lead to the diagnosis 
of a positive venous pulse. For comparison always 
observe the carotids at the same level. 

Note. — The cervical veins are under normal conditions insufficient 
— that is, a back pressure may cause pulsation of the jugular without any 
valvular lesions existing. This is the condition in Stokes-Adams disease, 
where a double auricular systole may be noted to every ventricular sys- 
tole (Erlanger's Experiments). — Editor, 

The Positive Venous Pulse: Is synchronous with 
the carotid pulse. The ascending wave begins be- 
fore the carotid and has an undulation in its middle. 
The early start is due to the fact that it begins at the 



METHODS OF PHYSICAL EXAMINATION 107 

closure time and the undulations are produced by 
the same factors as produce those of the negative 
pulse. 

Liz\cr Pulsations : Seen and felt to the right of the 
median line; is an expansile pulsation, and is to be 
distinguished from the transmitted aortic pulsation 
seen and felt in the epigastrium. This expansile pul- 
sation is seen in the liver, in tricuspid regurgitation. 

The Positive Centripetal or Penetrating Pulse: Is 
found in conditions of low arterial tension with 
marked celer pulse. Is usually associated with the 
capillary pulse, but it may be absent, as the capilla- 
ries are too small to show the pulsation, and it may 
not make its appearance until it is passed on to the 
smaller veins. This pulsation disappears when pres- 
sure is applied between the heart and the periphery. 
It is very rare. 

Diastolic Venous Collapse: Is due to adhesions of 
the heart with the thoracic wall and so during sys- 
tole, the negative intra-thoracic pressure being mark- 
edly diminished, there is a swelling of the veins. At 
the beginning of diastole there is a marked sudden 
collapse. This may be confused with the positive 
venous pulse, but on pressure upon the veins it disap- 
pears below the point of pressure. Combinations of 
the positive and negative pulse are impossible of 
diagnosis. 



DIFFERENTIAL DIAGNOSIS 

Pulmonary Diseases : 

Diseases of the Nose, Pharynx and Larynx. 
Stenosis of the Larynx. 
Trachea. 
Bronchi. 
Bronchitis: Acute, Capillary, 

Chronic, Dry, 

Fibrinous, Bronchorrhoea, 



Putrid. 



Bronchiectasis. 

Asthma, Bronchial. 

Asthma, Cardiac. 

Broncho Pneumonia (Lobular). 

Lobar Pneumonia. 

Cirrhotic or Interstitial Pneumonia. 

Pneumokoniosis. 

Emphysema: Acute, 

Compensatory, 

Interstitial, 

Atrophic. 
Cardiac or Brown Induration: 
Oedema: Inflammatory Stasis. 
Hypostatic Pneumonia. 
Atelectasis : 
Infarction. 
Abscesses: Primary, 
Embolic. 
Gangrene. 

io8 



DIFFERENTIAL DIAGNOSIS 



109 



Tumors : Primary, 

Metastatic. 
Parasites : Echinococcus, 

Actinomycosis. 
Mediastinal : Abscess, 
Tumors. 
Tuberculosis : Miliary, 

Pneumonic, 
Ulcerative, 
Fibroid, 



Pleurisy: Acute, Local, - 



Acute, 
Chronic, 
Broncho, 
Lobar. 
Encapsulated, 
) Diaphragmatic. 
f Dry, 
Serous, 
P , , Serofibrinous, 

' Purulent, 
Hsemorrhagic, 
Chylous. 



thickened 



Chronic, Fibrinous, 

Serofibrinous, . , 
Fibroid, ( P^^"-"^- 

Serous, 
Purulent. 
Hydrothorax. 
Haemothorax. 
Pneumothorax. 
Hydro or Pyopneumothorax. 
Cysts: Echinococcus. 
Inspection : 

Conditions in zMch a bulging of one side of the 
thorax is seen: 

Note. — As a clinical fact, bulging, except from bony deformity and 
tumors, is rarely seen. — Editor. 

Lobar Pneumonia. 
Pneumothorax. 



no XOTES ON PHYSICAL DIAGNOSIS 

Pleural effusions and conditions diminishing the 
negative pressure. 

Compensatory Emphysema. 
Spinal Qirvatures. 
Tumors : Thoracic and Abdominal. 
Conditions causing a refraction of one-half or a part 
of the thorax: 

Pulmonary Fibrosis. 

Tuberculosis, chronic. 
Cirrhosis. 
Chronic Pleuritic Thickening, after absorption of 
old pleural effusions, with poor pulmonary expansion. 
Spinal Curvatures. 

Conditions causing a decreased expansion of part or 
half of the thorax: 
Pain : Pleurisy, 

Fractured Rib, 
Neuritis. 
Pulmonary Infiltrations: Pneumonic, 

Tubercular, 
Fibroid, etc. 
Pleural Adhesions. 

All the conditions causing bulgings and retractions. 
Bronchial Stenosis. 
Tumors. 

Dyspncea : 

Inspiratory: Stenosis of the upper air passages, 
pharynx, larynx. 
Stenosis of the Trachea. 
Stenosis of one of the large Bronchi. 
Expiratory : Emphysema, 

Capillary Bronchitis, 

Asthma, 

Fibrous Bronchitis. 



DIFFERENTIAL DIAGNOSIS m 

Palpation : Fremitus is normal in 

Bronchitis : All varieties save capillary. 
Bronchiectasis (save over large cavities). 
Asthma: Bronchial. 
Pleurisy, Acute Dry. 
Brown Induration. 
Miliary Tuberculosis. 

Fremitus and voice sounds change correspondingly. 

Fremitus is normal in diseases of the upper respira- 
tory passages. 
Increased in: All conditions of Pulmonary Infiltrations, 
bronchi being open. 

Pneumonic, 

Tubercular, 

Fibroid, 

Atelectatic, 

Infarctions, 

Abscesses. 

Gangrenous, 

Tumors, 

Cystic. 

All cavities with thick walls. 

Bronchiectatic (General Bronchial Dilatation), 

Tuberculous, 

Gangrenous, 

Discharged Abscesses (resulting adhesions). 
Diminished or Absent in: 

All conditions of alveolar dilatation: 

Emphysemas, 

Capillary Bronchitis, 

Asthma. 

Conditions where the bronchi are closed: 

Tracheal and Bronchial Stenosis, 

Capillary Bronchitis, 

Fibrinous Bronchitis. 



112 NOTES ON PHYSICAL DIAGNOSIS 

All conditions separating the lung from the chest 
wall, as 

Air : Pneumothorax. 

Fluid: Pleural Effusions and Exudates, 

Hydrothorax, 

Hsemothorax, 

Pyothorax. 
Thickened Pleura : 

Chronic Fibrinous Pleurisy, 

Tumors, 

Cysts. 

Percussion : 

Conditions in zi'hich a Normal percussion note is ob- 
tained : 
Diseases of the upper air passages. 
Tracheal and Bronchial Stenosis. 
All forms of Bronchitis save Capillary. 
Bronchiectasis save over cavity. 
Asthma, Bronchial. 
Asthma, Cardiac. 
Brown Induration. 
Early Oedema. 
Miliary Tuberculosis. 
Acute Dry Pleurisy. 
Conditions in which Hyperresonance (vesiculo tym- 
panitic resonance of Flinty or Skoda' s resonance) is 
obtained: 
Dilated Alveoli. 
Emphysema: Acute, 

Chronic, 

Compensatory, 

Interstitial. 

Capillarv Bronchitis, 1 * , -r^. ^ 
^ , ^ y Acute Distensions. 

Asthma. 



DIFFERENTIAL DIAGNOSIS 113 

Conditions producing a relaxation of the lung tissue, 
as early inflammatory congestion, seen in: 

Early tuberculous infiltration, 
Oedema, 
Hypostasis, 

Pneumonia first and third stage. 
Relaxation of the lung tissue due to nearby in- 
filtrations : 

Tuberculous Infiltration. 
Bronchopneumonia. 
Lobar Pneumonia. 
Infarct. 
Abcesses. 
Tumors. 
Atelectasis from Pressure: 
Ascent of Diaphragm. 
Pleural Effusions and Accumulations. 
Pleural and Mediastinal Tumors. 
Pericardial Effusions and Enlarged Heart. 
The upper part of Lobar Pneumonic Infiltra- 
tion. 
Pneumothorax : Local, 

General. 
Cavities. 

Conditions in zvhich Dulness is obtained: 

All conditions of thickened pleura. 

All conditions of alveolar infiltration or partial con- 
solidation. 

Early Lobar Pneum.onia. 

Late Stage of Lobar Pneumonia. •' 

Broncho Pneumonia. 

Tuberculous Infiltration. 

Infarction (Small Multiple). 

Small Abscess. 

8 



114 NOTES ON PHYSICAL DIAGNOSIS 

Gangrene. 

Pulmonary Fibrosis. 

Metastatic Tumors. 

Pulmonary Oedema. 

Atelectasis. 

Hypostatic Pneumonia. 

Small Cavities and Consolidation. 

Slight Pleural Effusion. 

Enlarged Heart. ] p f * i 

Pericardial Accumulations. [ 

Conditions in zvhich a Flat Note is obtained: 

Complete Consolidation of Lung Tissue as in: 

Lobar Pneumonia. 

Tuberculous Consolidation. 

Pulmonary Fibrosis. 

Atelectasis (Marked). 

Hypostatic Pneumonia (Marked). 

Tumors. 

Abscess. ) ^ c 1-1 

Before discharge. 



Gangrene. 

Infarct (Large). 

Cysts. 

Mediastinal Tumors. 

Cavities Filled with Fluid. 

Pleural Accumulations of Fluid as in: 

Pleural Effusion (Large), 
Local, 
General. 

Hydrothorax. 

Haemothorax. 

Pyothorax. 

Pyopneumothorax. 

Tumors and Cysts (Large). 

Pneumothorax when air is under great tension. 



DIFFERENTIAL DIAGNOSIS nS 

Conditions in ziliicJi a true Tympanitic Note is ob- 
tained: 
Caznties of the lung superficially situated and under 

a certain tension : 
Tuberculous, 
Bronchiectatic, 

Gangrene, ) ^^^^^^ Discharge. 
Abscess, j ^ 

Local Pneumothorax, 
Diaphragmatic Hernia, 
Interstitial Emphysema. 
Auscultation of the Voice : 

Conditions in which Vocal Fremitus {the vibration 
produced \by the voice and appreciated by the ear 
listening over the chest) is absent: 
Pleural Exudates and Transudates : Local, 

General. 
Pneumothorax : Local, 

General, 
Thickened Pleura (Marked), 
Tumors of the Pleura, 
Obstructed Bronchus, 
Mediastinal Tumors, etc. 
Conditions in which Vocal Fremitus is decreased: 
Emphysema, 
Asthma, 

Capillary Bronchitis, 
Fibrinous Bronchitis, 
Brown Induration, 
Pneumokoniosis, 
Thick Pleura. 
Conditions in which Vocal Fremitus is found to be 
normal: 
Bronchitis, 
Dry Pleurisy, 



ii6 NOTES ON PHYSICAL DIAGNOSIS 

Miliary Tuberculosis, 
Very Early Tuberculous Bronchitis, 
All deep seated consolidations, 
Early Oedema, 

Small Scattered Areas of Consolidation (Broncho- 
pneumonia ) , 
Early Infiltration. 

Conditions in zvhich Vocal Fremitus is increased: 
All conditions of Pulmonary Consolidation, as : 
Broncho-pneumonia. 
Lobar Pneumonia, 
Tuberculous Pneumonia, 
Fibroid Pneumonia, 
Hypostatic Pneumonia, 
Atelectasis, 
Infarct, 
Gangrene, 
Abscess, 

Tumors and Cysts. 
All Cavities as : 
Tuberculous, 
Bronchiectatic, 
Abscess, 
Gangrene. 

The voice sounds are absent, decreased or normal 
under the same conditions as vocal fremitus. 
They are increased in: 

All early congestions and infiltrations of the Lung 
Tissue as in : 
Early Tuberculosis, 
Early Lobar Pneumonia. 
Deep Seated Consolidations as in: 
Central Pneumonia. 



DIFFERENTIAL DIAGNOSIS 117 

Scattered Areas of Consolidation as in : 

Broncho-pneumonia, 

Tubercular Broncho-pneumonia, 

Ad^ultiple Infarcts, 

Multiple Abscesses, 

Metastatic Tumors. 
All Pulmonary Consolidations as in: 

Lobar Pneumonia, 

Fibroid Pneumonia, 

Gangrene, 

Abscess, 

Tumors, Cysts, etc. 
Cavities (All Varieties) : 

Auscultation of the Breath Sounds : 
Changes in Rhythm: 
Interrupted : 

Nervous Patients, 
Pain, 

Early Infiltration, 
Pleurisy (Dry). 
Prolongation of Pause between inspiration and ex- 
piration : 

Inspiration is short as in: 

Pulmonary Consolidation. 
Expiration is delayed as in : 

Lost elastic Retraction as in emphysema. 
Expiration is prolonged in : 
Bronchitis, 
• Early Infiltration, 

Partial Stenosis of the Bronchioles, 

Asthma, 

Emphysema, 

Consolidations, 

Cavities. 



ri8 NOTES ON PHYSICAL DIAGNOSIS 

Alterations in the Intensity oj the Breath Sounds : 
Absent: 

Pleural Exudates and Transudates, 

Markedly Thickened Pleura, 
Pneumothorax, 

Tumors of the Pleura. 

Mediastinal Growths. 
Decreased: 

Emphysema, 

Asthma, 

Brown Induration, 

Thickened Pleura. 

Very Early Infiltrations as : 

Pneumonic, 
Tuberculous. 
Miliary Tuberculosis. 
Increased: 
Bronchitis, 
Bronchial Stenosis, 
Fibrinous Bronchitis, 
Infiltrations. 
Alterations in Quality : 
Harsh or Rude: 

Emphysema, 

Bronchitis, 

Early Infiltrations, 

Bronchial Stenosis, 

Miliary Tuberculosis. 
Broncho-vesicular (small consolidations) : 

Broncho-pneumonia, 

Tuberculous Infiltrations, 

Multiple Abscesses and Infarcts, 

Small Cavities. 
Bronchial or Tuhulous (all consolidations) : 

Lobar Pneumonia, 



DIFFERENTIAL DIAGNOSIS 119 

Tuberculous Pneumonia, 

Fibroid Pneumonia, 

Abscesses, 

Gangrene, 

Hypostatic Pneumonia, 

Atelectasis, 

Cavities (at times). 
N. B. — Tubular Breathing is characterized by having 
a higher pitched expiration than inspiration. 

In Cavernous Breathing the expiration is of the same 
pitch as the inspiration, or lower. 

Cavernous Breathing: 
Large Cavities. 

Amphoric with a Metallic Quality: 
Cavities. 

Rales. 

Pleuritic and Friction Rales: 

Dry Pleurisy, 

Above the fluid in pleural effusions, 

Pneumonia. 
Crepitant Rales: 

All early infiltrations and exudations into the al- 
veoli. 

The absorption stage in Lobar Pneumonia, 

Atelectasis, 

Miliary Tuberculosis. 
Siihcrepitant Rales: 

Capillary Bronchitis, 

'Dry Pleurisy (?) 

Early infiltrations. 

Miicotis Rales: 
All forms of Bronchitis save the dry and fibrinous., 
Small Cavities. 



I20 NOTES ON PHYSICAL DIAGNOSIS 

Mucous Gurgles: 

Cavities (all varieties that have fluid in them), 

Hydropneumothorax with fistulse below the fluid, 

Large Bronchi. 
Sibilant Rales: 

Asthma, 

Capillary Bronchitis, 

Emphysema, 

Fibrinous Bronchitis, 

Dry Bronchitis. 
Sonorous Rales: 

Bronchitis, 

Cavities. 



DISEASES OF THE PLEURA AND LUNGS 

Diseases of the Pleura. 

Pleurisy: When pleurisy without effusion exists 
the symptoms complained of by the patient, such as 
pain, fever, etc., help more in judging this variety of 
pleurisy than do the physical signs. 

Dry Pleurisy. Inspection: The patient lies on the 
back or on the affected side. The excursion of the 
thorax on the involved side is less than on the sound 
side. If pleural surfaces are very rough, the friction 
rub can be appreciated by palpation. Percussion gives 
a normal note over the involved area, but produces 
pain. The excursion of the edge of the lung is de- 
creased, due to restricted movement of the affected 
side or to adhesion of pleural surfaces. 

Auscultation: A sharp rale heard on inspiration 
and expiration, sounds close to ear placed directly 
on the chest, and is increased by pressure and deep 
breathing; at times this friction may be heard with 
the stethoscope."^ 

The murmurs differ from dry mucous rales in that 
they do not alter in character, position, intensity or 
number on coughing. However, the pleurisy may be 
combined with some catarrhal condition, in which 

* It is a most important point that early pleurisy may be entirely 
missed by using the stethoscope and not the ear directly upon the chest. 
— Editor. 



12 2 NOTES ON PHYSICAL DIAGNOSIS 

case the number, etc., may diminish, but location 
never. They differ from crepitant rales in that the 
latter are sharper, not so prolonged, and come at the 
end of the inspiratory act. 

Both pleuritic and crepitant rales become weaker 
after some time of deep breathing, but after a rest 
they return. 

The points characteristic of pleuritic friction are 
that they vary in quality as inspiration proceeds, are 
usually circumscribed, and extend into expiration. 

In rare cases all means fail in making a proper in- 
terpretation of sounds, so diagnosis must be with- 
held. 

If pleurisy is near the heart, the friction comes not 
only with the respiration, but also with the cardiac 
movements. It usually increases with deep inspira- 
tion. In miliary tuberculosis, with tubercles on the 
pleura, although no true pleurisy is present, a fric- 
tion sound is produced that is practically the same as 
that in dry pleurisy. 

All other symptoms may fail, such as cough, pain, 
etc., so that in this condition the friction rale is the 
essential point. 

Pleurisy with Eifusion. Inspection: The patient lies 
on the involved side or back, so that he can have the 
full use of the normal lung. The diseased half of the 
thorax is decreased in its excursion, the lower part 
first, and later, with the increase of the exudate, the 
upper part. The involved side is larger than the one 
not involved. The heart is displaced towards the 
sound side. The abdominal organs are displaced 
downward from sinking of diaphragm, as is shown 



DISEASES OF THE PLEURA AND LUNGS 123 

by palpable liver and spleen. These latter organs 
must be palpated directly as they move but little on 
inspiration. The diaphragm assumes more or less 
the inspiratory position. 

Pulsations of exudate are found mostly on the left 
side, with overacting large heart and with the relaxa- 
tion of the costal muscles due to inflammation as in 
empyema. This may be local empyema, or aneurysm. 

Percussion is the most reliable. The note is flat, 
and there is an increased resistance to the finger. 
The upper line of dulness may be oblique, higher pos- 
teriorly than anteriorly, or the reverse, or even higher 
in axillary line than in front or behind. Adhesions, 
position of the patient during the accumulation, or 
excess of inflammatory lymph between pleural sur- 
faces above the line of the fluid, or compression of 
the lung may cause these variations. The fluid 
changes its level when the patient changes his posi- 
tion, but this takes place slowly, due to the adhesion 
of pleural surfaces about the fluid, w^hich, if very firm, 
prevents entirely this change of level. Above the 
level of the fluid the lung gives a tympanitic, deeper 
note, due to its relaxation. At times cracked pot 
tone is obtained when the lung is compressed and 
the bronchi stenosed. Below the clavicle, in marked 
compressions, Williams' tracheal note is obtained. 

Exudates of 300 c. c. and less give no dulness. 
Shghtly larger ones give dulness on Hght percussion. 
This is best demonstrated by percussing all over one 
side of the chest from the axilla dow^n, with the pa- 
tient in the upright position, then allowing patient to 
lie on his side supported on his elbow. Palpation: 



124 NOTES ON PHYSICAL DIAGNOSIS 

Fremitus is absent over fluid, or weakened above 
fluid. It is increased, if the compressed lung lies 
close to the chest. When present below the level of 
the fluid it may be due to adhesions, or to markedly 
compressed lung above, being close to chest wall and 
then setting the whole chest wall in vibration on that 
side. 

Auscultation over fluid of moderate quantity gives 
diminished murmur, or no murmur at all. If the 
lung above is merely relaxed and not compressed, 
murmur is absent. If compressed, marked tubular 
breathing is heard over lung and weak tubular 
breathing over fluid. 

The voice is increased over compressed lung, di- 
minished over fluid, or present for the same reasons 
as given for presence of fremitus. 

In moderate exudates posteriorly near scapulae, 
aegophon}^ may be heard, due to waves of voice sound 
passing to the smaller bronchi that lie close together, 
thus interrupting the vibrations. This may be heard 
over the chest of healthy children, and at times over 
infiltrated lung. 

Note. — yEgophony (goat bleating sound), a broken series of sounds. 
Only the higher notes in the sound wave reach the ear; the lower ones 
are inaudible, due to certain physiological and pathological conditions. — 
Editor. 

At the line of fluid a friction murmur can be heard. 
This is rare and must not be confused with crepitant 
rales of compressed lung. 

Other signs have little value, as they are found in 
other diseases. 

The pulse is small as diastole of the heart is dimin- 



DISEASES OF THE PLEURA AND LUNGS 125 

ished by tendency to positive pressure in tiiorax, 
lessened sucking action on veins, and a retarded cir- 
culation through the lungs. The arteries on this 
account are not well filled, and CO2 accordingly rais- 
ing the blood pressure, and causing the blood to flow 
slowly through the capillaries. Cyanosis and dyspnoea 
vary with the extent of the fluid, etc. 

Differential Diagnosis:- If no dulness be present and 
typical rales are heard, the diagnosis of dry pleurisy 
may be made. At times rales are absent though dry 
pleurisy exist. In this case, if pain be present, which 
is increased on local pressure and made worse by deep 
breathing, sneezing and coughing, a probable diagno- 
sis can be made. 

Muscular rheumatism must not be overlooked, as 
all the above manipulations increase pain in this con- 
dition. By pinching the muscle, the pain is materially 
increased in rheumatism, while faradization decreases 
it. 

Periostitis and caries of the ribs may give local 
manifestations and be also associated with pleurisy. 
Intercostal neuralgia at times cannot be dift'eren- 
tiated, as the pleurisy may involve the nerves and give 
rise to an associated neuritis with characteristic ten- 
der points. As a rule, pleurisy is not so local, and the 
pain is more apt to be increased on deep breathing. 
The application of the anode of a constant current 
does not diminish the pain. As the pain of pleurisy 
may be referred to the terminations of the intercostal 
nerves in the epigastrium, this may simulate gastral- 
gia, gastric ulcer, gall stones, or peritonitis. The di- 
agnosis of pleurisy without hearing the friction rales 



126 NOTES ON PHYSICAL DIAGNOSIS 

should be made with the greatest caution. To dis- 
tinguish pleural exudate from pulmonary consolida- 
tion, is at times difficult, as in the first condition the 
voice fremitus and tubular breathing may be present 
and even be increased, while in consolidation, when 
the bronchi are stopped, all these signs may fail. The 
chief points of difference, aside from the cause of the 
disease, are the following : 

Pneumonia : Pleural Exudate : 

PercKsstoji. 
The dulness is never absolute The dulness is absolute and in- 
and diminishes from above down. creases from above down. 
Voice So tends. 
Bronchial voice or breathing is These are less over the flattest 
present and is loudest over the area and segophony is present, 
dullest area, ^gophony is absent, 
and is brought out by coughing. 

J^a/es. 
Crepitant rales are heard over Are not heard well over the flat 
the dullest area. area, but over upper edge of same. 

Displaceme7it. 
Displacement of other organs is Is more or less marked accord- 
slight, ing to the extent of the exudate. 

The diagnosis of cavities, from sacculated empy- 
ema may be difficult, as both give the same physical 
signs and puncture results in pus. After the expec- 
toration of large quantities of pus from cavity the 
signs change. Mediastinal tumors are diflicult to 
diagnose. They usually give irregular outlines on 
percussion, and are located in the upper part of the 
chest. They cause special symptoms and give dull 
" processes " to the normal side, etc. In this con- 
dition no fluid may be obtained on aspiration from 
the pleura as the needle goes through soft inflamma- 



DISEASES OF THE PLEURA AND LUNGS 127 

tory lymph and is plugged, or the needle is not long- 
enough or of large enough calibre. Flakes of fibrin 
may plug the needle, or the exudate may be so thick, 
that it does not flow well, or the needle may get 
lodged in adhesions of the lung tissue. 

Aneurysm and Pulsating Local Pleurisy: The latter 
are usually situated low down, and are increased by 
deep expiration. The absence of murmur, pressure 
symptoms, change in the pulse and distal vessel mur- 
murs will serve to differentiate pulsating pleurisy 
from aneurysm. Peripleuritic abscesses have in com- 
mon with pleurisy the same physical signs, save that 
there are no signs of compressed lung, friction 
sounds or displaced organs. 

Note. — Pulsating pleurisy is rare and is practically always due to pus 
formation. — Editor. 

Subphrenic Abscess: The edge of the lung moves. 
When the trocar is introduced the inspirations ac- 
celerate the flow, while expiration retards it, which is 
opposite to the condition found in pleural exudate. 

Enlarged Liver or Spleen: The displacement is usu- 
ally downward. 

Hccmothorax: History of the injury, aneurysm or 
gangrene and symptoms of exsanguination. The only 
way to definitely determine this is by puncture, which 
must be repeated several times if blood is obtained, 
as the needle may enter a vessel in the pleura or lung 
and pure blood be withdrawn. ' If blood-tinged fluid 
is withdrawn, as occurs in hsemorrhagic diathesis, tu- 
berculosis or cancer, this does not indicate hsemo- 
thorax in the true sense, as the fluid is blood, mixed 
with serum. 



128 NOTES ON PHYSICAL DIAGNOSIS 

Hydrothorax: The fluid in this condition is much 
more readily movable, and is usually associated with 
heart, kidney or liver disease or with cachexia. The 
other signs are the same as for any fluid in the pleural 
cavity. Having demonstrated the presence of the 
exudate, it is now necessary to find out its character, 
whether serous, purulent, bloody or decomposed. 
The general symptoms, history and course of the case 
are, as a rule, reliable indices. The puncture is the 
only sure means, and in the case of pus several must 
be made if fluid is not obtained with the first punc- 
ture. When pus is suspected, the puncture must be 
made low down, as the cellular elements sink and 
leave the upper fluid only turbid. Bacteria in the so- 
called idiopathic variety of pleurisy are undoubtedly 
of tuberculous origin; pneumococci, staphylococci, 
streptococci and tubercle bacilli have been found on 
the pleura without suppuration. Later, however, 
these favorable conditions may develop and pus ap- 
pear. Pleurisy in rare cases may be associated with 
rheumatism, and the typhoid bacillus has been found 
in some cases. Their mode of entrance into the 
pleura is not known. The cause of pleurisy must now 
be determined. AVe have primary and secondary 
pleurisy, the first being more apparent than actual. 

Rheumatic pleuris}^ (Fielder) in which the pleurisy 
is the first manifestation, the joint affections, endo- 
carditis, etc., following it. Some cases of apparent 
primary pleurisy with a sudden onset, high fever, 
herpes, etc., may be classed as secondary to a 
focal lobar pneumonia. Blows on the chest cause 
an area of decreased resistance and a field for in- 



DISEASES OF THE PLEURA AND LUNGS 129 

fection. Cold acts in the same way by reducing 
the resistance. 7/ie great majority of primary 
pleurisies, if not all, are due to the tubercle bacillus 
from small tuberculous nodes at the apex extend- 
ing to the pleura, or to bursting of small tuberculous 
brojichial glands. At times the onset simulates a 
latent tuberculous affection. The following facts go 
to prove the above : Pleurisy in those with hereditary 
taint; history of former tuberculous disease in some 
part of the body; tuberculous glands, etc., found post 
mortem ; tuberculosis developing later in life ; tuber- 
culosis produced in animals by inoculation. 

Secondary pleurisy is usually due to extension from 
the neighboring structure, as the lung, thoracic wall, 
spine, neck, abdominal viscera, heart or mediastinum. 
A second class is that form introduced by the blood, 
either by diminished resistance from nephritis, gout, 
sepsis, syphilis, chronic diseases in the chest, as aneu- 
rysm, tumors, etc. 

Pneinnothorax : May come on suddenly with dysp- 
noea and cyanosis, or there may be no such manifes- 
tations, the condition coming on with no distress. 
Unilateral pneumothorax is one of the easiest condi- 
tions of the thorax to diagnose. The diseased side is 
enlarged. The intercostal spaces bulge* and neigh- 
boring organs are displaced to the opposite side. 
The patient lies on the diseased side and breathes 
rapidly, and the fremitus and voice are weak or 
absent. The percussion note varies with the ten- 
sion of the air in the cavity, the presence or ab- 
sence of fistulae and fluid. Above the flu'' a nor- 

* See note, page 29. 



I30 NOTES ON PHYSICAL DIAGNOSIS 

mal note is obtained or hyperresonance. (Skodaic 
resonance or Flint vesiculo-tympanitic note.) If 
the air is under tension, a tympanitic or metallic 
tone can be obtained, the latter best by auscul- 
tating with the ear, and striking a pleximeter with 
a hard substance. If fistulae be present, the cracked 
pot note and the change of note on opening and 
closing the mouth are obtainable (Wintrich's note). 
These latter two signs are best demonstrated in 
those cases where a large cavity has ruptured and 
connects with a large bronchus. The change of note 
on respiration is present, i.e., a higher and fuller note 
on deep inspiration than expiration. A satisfactory 
explanation has not been given for this. Biermer's 
sign, where the tone is deep on standing, high on ly- 
ing down, is present, and this change of note is par- 
ticularly noticeable when a metallic tone is present. 
This is due to the fluid pushing down the diaphragm 
in the sitting position and thus enlarging the cavity. 

Auscultation gives the most pregnant results for 
diagnosis. The breath sounds (tubular breathing due 
to the compressed lung), voice and mucous rales have 
a metallic quahty. When the fluid drops from the 
lung or thoracic wall, striking the surface of the 
fluid, the " falling drop " (metallic tinkle) sound is 
heard. In rare cases the heart sounds have a metallic 
tone. Succussion is an absolutely diagnostic sign of 
pneumothorax or large cavities in the chest. "^ 

Differential Diagnosis: A marked left-sided con- 
tracting fibrosis of the lung may draw the diaphragm 
and stomach well up into the thorax, giving over the 

* See page 50. 



DISEASES OF THE PLEURA AND LUNGS 131 

lower portion of the thorax absence of breath sounds, 
tympanitic percussion and succussion. In these 
cases the affected side is not enlarged, but rather con- 
tracted, and the succussion comes with gastric as well 
as with respiratory motion; on washing out the stom- 
ach the succussion disappears. 

Diaphragmatic hernia, where the stomach and co- 
lon pass into the thorax, gives the signs of pneumo- 
thorax. Here the metallic notes are more dependent 
on the peristaltic movements than on the respira- 
tory and by washing out the stomach the succussion 
is lost. 

A pyopneumothorax hypophrenicus is an accu- 
mulation of gas and pus between the liver and the 
diaphragm on the right side, due to the rupture of 
some intestinal viscus. A similar condition can occur 
on the left side from the perforation of a gastric ulcer. 
Previous gastric or duodenal ulcers, typhoid, peri- 
tonitis, appendicitis, abscess of the liver and spleen, 
peri-nephritic abscess, tuberculous cavities at the 
base of the lung and trauma are some of the eti- 
ologic factors which, according to Leyden, are aids 
in the diagnosis of this condition. The signs are 
marked downward displacement of the liver, with 
slight displacement of the heart and lung edge, and 
an absence of bulging interspaces. The presence 
of vesicular breathing to the edge of the dulness or 
tympany. On puncture the needle is depressed on 
inspiration, and the fluid is under greater tension 
than on expiration, due to the movements of the 
diaphragm. 

Sacculated pneumothorax, as compared to a large 



13 2 NOTES ON PHYSICAL DIAGNOSIS 

cavity, is rare, so cavity should first be considered by 
the chnician. All the symptoms of general pneumo- 
thorax fail over the sacculated area save succussion, 
and this latter is almost never heard in cavities. 
Fremitus and voice sign and changes of note on open- 
ing and closing the mouth, sinking of the interspaces, 
together with change of the signs after expectoration, 
suggest cavity. All the other signs of cavity may be 
present in local pneumothorax, especially if there be 
an opening in the lung. There is nothing significant 
in the location of a cavity, as pneumothorax may be 
at the apex, due to some small tuberculous cavity 
rupturing, and cavities, the result of gangrene and 
abscess, etc., may be found at the base. 

TJie Diagnosis of Special Forms of Pnciiinothorax: 
Having demonstrated that pneumothorax is present, 
the next step is to determine its kind. This is im- 
portant for the therapy and prognosis. We have to 
distinguish between : 

Closed. 

Fistulous (i.e., the air entering and passing out of 
the cavity on inspiration and expiration). 

Valve fistula: {i.e., the air entering on inspiration, 
but not passing out on expiration). 

Change of note on opening and closing the mouth 
points toward the closed variety. Large gurgles (if 
the opening is below the line of the fluid) and the ex- 
pectoration of serous pus on the patient assuming 
certain positions point towards the fistulous variety. 
This last, however, may be absent when most ex- 
pected. According to Weil, the displacement of the 
heart and diaphragm in open pneumothorax is pres- 



DISEASES OF THE PLEURA AND LUNGS i33 

ent, but not to so great an extent as in the closed va- 
riety. This displacement in the open variety is due 
to the lost negative pressure on the affected side. 
Testing the gas pressure by the trochar and mano- 
meter shows a higher pressure in the closed than 
in the open variety. According to Ewald, CO2 below 
5 per cent, points towards the open form, above 10 
per cent, to the closed. This last is neither prac- 
tical nor reliable. If an opening in the thorax exist, 
one can tell if there is a hole in the lung by asking the 
patient to take a deep breath while closing the ex- 
ternal w^ound with the finger, and on removal of the 
latter there should be, if a fistula in the lung be pres- 
ent, no inrush of air. In the closed form the displace- 
ment of the organs is greater, and the affected side is 
greatly enlarged. A distinct fistulous murmur is ab- 
sent, though metallic rales and breath sounds may 
come from the retracted lung. The change of note 
on percussion in changing the position of the patient 
is present, but the change on opening and closing the 
mouth is absent. With an increase in the tension of 
the gas the fremitus is greatly diminished. 

Ventile pneumothorax is a valve-like fistula that 
allows air to enter but not to leave a cavity. Here the 
signs soon change to the closed form, with a greatly 
distended thorax, that is increased by the exudations 
of fluid. Absence of expectoration of the exudates is 
to be expected. 

The Etiological Diagnosis: Nine-tenths of the cases 
are due to pulmonary tuberculosis, with a small cav- 
ity rupturing before adhesions have formed. Other 
causes of cavity lead to it, such as bronchiectasis. 



134 NOTES ON PHYSICAL DIAGNOSIS 

gangrene, cavity, foreign bodies lodged in the lung, 
bursting of emphysematous alveoli on straining. 
Rupture of the intestines or stomach from ulceration 
may cause pneumothorax, although here it is apt to 
produce a hypophrenic pyopneumothorax. Lastly, 
according to Levy, a gas producing bacterium in the 
pleural exudate may produce pneumothorax. 

Note. — It must never be forgotten that an inexpert use of the 
aspirator in removing fluid from the plural cavity may produce pneumo- 
thorax. This is a serious and unpardonable accident. — Editor. 

Neoplasms of the Pleura. 

Primary are diagnosed with great dii^culty. Aside 
from the general manifestations of cancer or sar- 
coma, the signs may be those of pleural effusions, 
thick pleura, or mediastinal tumor. The puncture 
reveals a bloody or dark fluid with altered cells, blood, 
fat, and perhaps pieces of tumor either stuck to the 
needle or floating in the exudate. If the costal pleura 
is involved, a long needle is needed as short ones give 
negative results. The affected side may bulge or re- 
tract, as the case may be. The diagnosis must be 
made on the cachexia, metastases, glandular swell- 
ings, and perhaps the growth of the tumor externally. 

EcHiNococcus OF Pleura. 

This gives signs of pleural exudate with a displace- 
ment of the organs, etc., and no fever. The diagnosis 
is made by puncture, the aspirated fluid being free 
from albumin and containing hooks and bladders. 



DISEASES OF THE PLEURA AND LUNGS 13 5 

If the cysts suppurate the hooks alone differentiate 
the condition from empyema. 

Diseases of the Trachea. 

Local diseases of the trachea are rare when not 
combined with diseases of the larynx on the one hand, 
or of the bronchi on the other. The organ can best 
be investigated with the laryngoscope. 

Diseases of Bronchi and Lungs. 

Bronchial Stenosis: Is usually an easy diagnosis 
to make if the larger bronchi are involved. Dyspnoea 
is the most marked characteristic symptom, and 
the degree of the same is dependent on the 
rapidity of the onset of the stenosis. The pic- 
ture differs according to the position of the stenosis, 
whether the lesion is above or below the bifurcation. 
The stenosis of the finer bronchi is not included 
under this head, as the symptoms are dift'erent, 
as seen in capillary bronchitis and asthma. The 
symptoms are dyspnoea, cyanosis and those of irrita- 
tion of the vasomotor centers by CO2. The pulse is 
slow and full, and the tension is high and shows on 
the sphygmographic tracing marked variations of the 
respiratory blood pressure. In some cases a distinct 
pulsus inspiratorius intermittens can be seen. The 
prolonged phases of the difficult breathing retard the 
venous flow and diminish the respiratory acceleration 
of the blood in the pulmonar}^ vessels, thus leading 
to venous congestion, dilatation of the right heart, 
swelling of the liver and a decrease in the quantity of 



136 NOTES ON PHYSICAL DIAGNOSIS 

urine. The type of respiration is that of inspira- 
tory dyspnoea, the auxihary muscles of respiration 
standing out distinctly. The number of respira- 
tions is decreased as air enters the lung slowly, and 
the expiratory stimuli are delayed in reaching the 
brain center. As there is a decreased quantity of air 
inflating the lung, the movements of their borders are 
distinctly Hmited. With the increase of the negative 
pressure within the thorax on inspiration there is a 
marked sinking of the supraclavicular fossae, the free 
edges of the ribs and the epigastrium. The above 
symptoms indicate that there is an obstruction of the 
air passages that causes difficulty in inspiration. On 
percussion one finds no change of note over both 
lungs. This throws out all those conditions causing 
dyspnoea from obliteration of alveoli by infiltration, 
transudation, exudation of the lung tissue, or destruc- 
tion of lung tissue by gangrene, abscess, tumors, com- 
pression of the lung as from pleural exudates, trans- 
udates, tumors, and air. 

By the auscultation signs cardiac dyspnoea can be 
excluded. The vesicular breathing is markedly di- 
minished and also the voice and fremitus. These facts, 
taken in conjunction with a normal percussion note, 
are characteristic. Besides these a whistling or rasp- 
ing stenotic murmur can be heard even some dis- 
tance from the chest. Now that the diagnosis has 
been made of stenosis of the upper air passages, we 
must determine where it is situated and what the 
cause is. 

Laryngeal Stenosis: The head is thrown back and 
the thyroid cartilage moves up and down with inspira- 



DISEASES OF THE PLEURA AND LUNGS i37 

tion and expiration. A loud stenotic murmur is 
heard over the larynx. Laryngoscopic examination 
reveals a lesion such as croup, oedema, a foreign body, 
etc. Do not forget that a bronchial stenosis may be 
associated with this condition. 

Tracheal or Bronchial Stenosis: The head is stretched 
forward and the thyroid cartilage moves little. Nega- 
tive result on laryngoscopic examination. Due to 
the lack of sufficient air passing to the lung, the in- 
spiratory retractions are more or less marked. The 
symptoms vary accordingly as the stenosis is above or 
below the bifurcation. Where one large bronchus is 
stenosed, the corresponding half of the thorax does 
not expand, while the other half has excessive ex- 
pansion and the lungs become overinflated. The 
diaphragm is pushed down and the lung edges are 
lower than normal and nearby organs are covered. 
On the diseased side the percussion is resonant. Fre- 
mitus, voice and the respiratory murmur are de- 
creased, and a stenotic murmur can be heard and felt. 
Weakness of voice or the presence or absence of voice 
indicates little. Having located the lesion, now de- 
termine its cause. 

Conditions External to the Bronchi: Struma is the 
most frequent cause and especially the post-sternal 
variety. Tumors of the oesophagus com.e next. Never 
introduce a sound in attempting to diagnose this con- 
dition, as when one gets tracheal stenosis there is apt 
to be some oesophageal stenosis and the results are 
misleading and the procedure is attended with great 
danger to the patient. Aneurysm comes next, and 
can usually be diagnosed. Aneurysm may cause 



138 NOTES ON PHYSICAL DIAGNOSIS 

not only tracheal but also bronchial stenosis. Medi- 
astinal and lung tumors have produced the con- 
dition as also enlarged bronchial glands, especially 
when tuberculosis of the lung is present. Peri- 
cardial exudates and enlarged left auricle have been 
known to cause bronchial stenosis. Caries and ab- 
scess of the spine are also causative factors. Condi- 
tions zvithin the bronchi. In bronchitis fibrinosa, as a 
rule, one gets an expectoration of casts, etc. Inflam- 
matory thickening of the bronchial wall in bronchitis 
is rare, and is probably diagnosed by exclusion only. 
Tumors of the bronchial wall are considered in the 
same hght as the last named. A diagnosis of carci- 
noma of the walls is made where there is bloody ex~ 
pectoration, no fever, unaccountable cachexia and a 
swelling of the glands in the neck and axilla. Acute 
oedema after inhalation of steam or flame. Syphilitic 
stenosis is usually at or near the bifurcation, and one 
has bloody sHmy sputum and other signs of syphilis. 
Ulcers of the larynx. After a tracheotom.y the forma- 
tion of granulation tissue in the small trachea of a 
child may also lead to stenosis. In foreign bodies 
the history helps, and the fact that changes of position 
alter the symptoms. Do not forget that a body can 
pass to the bronchi and cause no symptoms at the 
time, but may later, wath an inflammatory reaction 
at the point of lodgment set up a stenosis. Hysterical 
stenosis is due to a spasm of the tracheal or bronchial 
muscles. 

Catarrhal Bronchitis: The swelling of the bronchial 
mucous membrane and the secretions from the same 
give signs that may be palpated and auscultated. 



DISEASES OF THE PLEURA AND LUNGS i39 

There is no change of percussion note in uncompli- 
cated cases. The larger the bronchi involved, the less 
the signs and symptoms and the smaller the more 
marked. Catarrh of the large tubes gives cough 
together with palpable and audible rales of large size, 
which latter depend for their size and quality on 
the quantity and character of the secretion. As the 
other smaller bronchi are affected, one gets fine 
mucous rales. The size, character, etc., is dependent 
on their location and the character of the secretion. 
The respiratory murmur is changed, in that it is 
harsher and expiration is prolonged. This is due to 
the stenosis of the medium-sized bronchi through 
swelling, secretions and perhaps spasm. On the 
plugging of a bronchus the voice, fremitus and mur- 
mur may be absent, but all may return after cough- 
ing. Sudden attacks of slight dyspnoea may be due 
to the latter. When stenosis of the bronchi exists 
expiratory effort and coughing cause retardation of 
the venous emptying, to which is added the slight de- 
crease in the excursion of the lung. This all tends 
to dilate the right heart, swell the liver, diminish the 
urine and produce cyanosis. However, these symp- 
toms are slight and never so great as in emphysema. 
We get emphysema and peribronchial induration of 
the lung in all cases of chronic bronchitis. Chronic 
bronchitis differs from the acute only in the history, 
sequels and a tendency to involve the finer bronchi. 
The etiological factors are inhalations, gas, intoxica- 
tion, infection, alcohol, etc. Constitutional diseases, 
as nephritis and congestion (cardiac). 

Putrid Bronchitis: Is a rare disease. The general 



I40 XOTES OX PHYSICAL DIAGXOSIS 

signs are those of chronic bronchitis with a foul spu- 
tum. This sputum differs in no way from that of 
bronchiectasis, and at times it is impossible to dis- 
tinguish the conditions from one another. Only 
signs of cavity and the characteristic periodic expec- 
toration of large quantities of sputum serve to dis- 
tinguish bronchiectasis. 

Gangrene of the Lung: Unless elastic fibres be 
found, the diagnosis is difficult, and only when cavity 
signs appear can a conclusion be drawn. Local em- 
ph3'sema may give the same kind of sputum and dif- 
ferential diagnosis from the last two diseases is 
especially difficult. Only by change of sign on ex- 
pectoration and the distinct purulent character of the 
sputum is the diagnosis possible. In all these condi- 
tions the history and the other symptoms must be 
resorted to. 

Capillary Bronchitis: Is chiefly found in children, 
and is characterized by dyspnoea due to the occlu- 
sion of the finer bronchi, is not at all relieved by 
coughing, and is attended by slight expectoration. 
With the difficult breathing, venous stasis, COo poi- 
soning, etc., appear. Aside from the cyanosis, etc., 
the most striking feature is the sinking in of the epi- 
gastrium and the hypochondrium, due to the difficulty 
with which the air enters the alveoli on inspiration. 
The upper smaller bronchi, not being so much in- 
volved and the air passing through them readily, the 
violent inspiratory act distends the alveoli in this part 
of the lung. Due to the plugging of many fine 
bronchi, the voice is decreased. There is no change 
of the percussion note, unless atelectasis or pneu- 



DISEASES OF THE PLEURA AND LUNGS 141 

monia is present. In atelectasis, by placing the pa- 
tient on the side opposite to the dulness after cough- 
ing and deep breathing, the dulness passes away. In 
early bronchopneumonia there are no signs, save the 
increase of fever and the constitutional symptoms. 
Only later do signs of infiltration become distinct. 

Miliary Tuberculosis: The signs and the picture 
may be the same, however the location of the rales at 
the apex, rather than at the base, the history, severity 
of the constitutional symptoms and large spleen, and 
the choroidal tuberculosis, all point to the latter dis- 
ease. The physical signs are auscultatory. The 
breathing is vesicular, but with prolonged, harsh ex- 
piration. Below and behind fine mucous rales are 
heard differing from the crepitant in that they come 
both in inspiration and in expiration and that they are 
variable with coughing, breathing, etc., and have no 
constant character. The cough is marked at first, 
but in weak children or in old people it may be absent. 
The expectoration is absent or very slight. When it 
is coughed up and put in water, the mucous from the 
large tubes floats on top and from these fine strings 
come down which examined under the microscope 
show^ a central fibre with a corkscrew arrangement of 
material about it. The whole thing is made up of 
mucus (Hoffmann) due to the mucus being com- 
pressed in the fine tubes by coughing. The spiral ar- 
rangement may be due to twists in the tubes. These 
are not characteristic at all, as they are found in bron- 
chitis fibrinosa, asthma, and in lung infiltrations. 

Fibrinous Bronchitis: The diagnosis is made on get- 
ting casts that are made up of fibrin in layers with 



142 NOTES ON PHYSICAL DIAGNOSIS 

cells in them and some blood. When they form m 
large branches they give signs of bronchial stenosis 
and occlusion which is relieved on expectoration of 
the casts and returns with the formation of new ones. 
Etiological factors help little. It is found in diph- 
theria, pneumonia, scarlet fever, and in tuberculosis. 
It is supposed to be a staphylococcus infection of the 
bronchi. 

Bronchiectasis : The characteristic symptom is the 
periodic expectoration of large quantities of sputum, 
while between times there is little or no cough or ex- 
pectoration. This is due to the diseased enlarged 
bronchial wall having little excitability. It is only 
when the secretion overflows or by position of patient 
flows on the normal mucous membrane, that a stimu- 
lus is given and an attack of coughing induced which 
lasts till the cavity is emptied. The sputum contains 
elastic and fibrous tissue and pus cells. Blood cells, 
"hsematoidin and Charcot crystals may also be found. 
The sputum, when allowed to stand in a glass, sepa- 
rates into three layers and contains pyogenic organ- 
isms. It is a septic condition, hence the fever. 
The sign of cavity may or may not be present. 
The presence of the signs depends upon whether 
the cavity is full or not. If the cavity is near to 
the surface and surrounded by a thick wall, the 
changes from the signs of consolidation to those 
of cavity after expectoration are very characteris- 
tic. Constant large mucous rales located at one spot 
near the edges or the base of the lungs are strong 
evidence in favor of bronchiectasis (Sahli). In the 
area of large cavities, the excursion of the lung is de- 



DISEASES OF THE PLEURA AND LUNGS i43 

creased and the chest may be sunken. As the bron- 
chiectatic cavities are met with in tuberculosis, the 
faihire of finding tubercle bacilli in the sputum after 
many examinations and the other symptoms point to 
bronchiectasis. If the cavities are at the apex the ex- 
pectoration is not so periodic, and the elastic fibres 
are in the sputum in great numbers, and the diagno- 
sis of tuberculosis should be made. Don't forget that 
bronchial cavities are met with at the apex. Hyper- 
trophy of the right heart, etc., helps little, as this is 
often seen in tuberculosis. It is almost impossible 
to make a dift"erential diagnosis from a sacculated 
empyema that has ruptured into a bronchus. All the 
physical signs are alike, and the periodic expectora- 
tion of material is the same. The presence of large 
numbers of haematoidin and cholesterin crystals points 
towards empyema, as these form after the process has 
lain dormant for some time. The history of the 
sudden expectoration of pus helps, and if it breaks 
through the chest wall, even then the diagnosis is not 
certain, as cavities in the lung may do the same. In 
gangrene of the lung the process is quicker, the spu- 
tum has a peculiar odor, and the elastic fibres retain 
their alveolar structure. More difficult and almost 
impossible is a diagnosis from putrid chronic bron- 
chitis with a diffuse uniform enlargement of the tubes. 
Complications, as joint affections, brain abscesses; 
etc., are hard to ascribe to the lung condition, but 
must be kept in mind. Brain abscess following bron- 
chiectasis is very frequent, especially where the bron- 
chial glands suppurate. Aside from the sHght blood- 
streaked expectoration, profuse hemorrhage may oc- 



144 NOTES ON PHYSICAL DIAGNOSIS 

cur, and in this connection tuberculosis must be kept 
in mind. 

Bronchial Asthma : Only zvJien tJie astJinia is due 
to nervous conditions, and there is no pathological 
change in tJie body, aside from the nervous system, is 
the condition considered one of true bronchial asthma. 
The symptoms are simple. The attacks of expiratory 
dyspnoea with utilization of the expiratory muscles 
and the slowing of respiration, together with signs of 
stasis and cyanosis. With the stenosis of the finer 
bronchi there is an acute distension of the lungs, espe- 
pecially of the upper portion. This can be shown by 
the deep position of the lung edges, and the oblitera- 
tion of the cardiac flatness. The excursions of the 
lung are diminished, and on percussion a box tone 
note is obtained over the whole of the thorax. On 
auscultation the vesicular breathing is decreased in 
intensity, but is harsh in quality with a prolongation 
of expiration, all being due to the fact that little air 
circulates in the lung, and what does, has to pass the 
stenosed bronchi, and is under higher pressure dur- 
ing expiration than normally. Whistling, sibilant 
and sonorous rales are heard. Few mucous rales are 
heard. The above applies only to the attack. To- 
ward the close of the attack there are many mucous 
rales of all sizes, etc. This is due to an acute con- 
gestion of the mucous membrane of the bronchi from 
some vasomotor disturbance (Stoerk). During the 
attack the pulse is small and of a high tension (CO2 
poison). The heart tones are faint from the cover- 
ing of the lung, etc. The differential diagnosis: The 
expiratory dyspnoea throws out all those conditions 



DISEASES OF THE PLEURA AND LUNGS i45 

causing inspiratory dyspnoea, as stenosis of the larynx, 
trachea, and the larger bronchi. Emphysema and 
chronic bronchitis have expiratory dyspnoea. In the 
two last-named conditions there is a distinct patho- 
logical change present which gives signs between at- 
tacks. Asthma being a pure neurosis, gives no signs 
between the attacks, the lungs being normal. How- 
ever, at times there are acute asthmatic attacks in 
these conditions that can be ascribed to no increase in 
the secretion or swelHng of the mucous membrane. 
In these conditions we have to deal with a spasm of 
the bronchioles brought on by some reflex condition, 
as gastric irritation, cold air on the back, accumula- 
tion of Curschmann's spirals or Charcot's crystals 
supposed to cause spasm of the smaller air passages. 
The spirals and crystals are found also in other con- 
ditions, but not in such numbers as in asthma. They 
are numerous during the attack of asthma, but in ex- 
ceptional cases may be absent. That they have noth- 
ing to do with the attack is shown by the fact that 
they may be found in great number in the sputum 
of asthmatics between the attacks. Schmidt found 
small fibrous plugs in asthmatic sputum that differed 
from the spirals in that they are made up of fibrin 
and not of mucus. Spasm of the glottis gives in- 
spiratory dyspnoea, moving of the larynx, no acute 
distension of the lung, sinking of the epigastrium on 
inspiration and an attack of short character, while the 
asthmatic attack lasts two or three hours at least. 

Cramp of the diaphragm is inspiratory, and all the 
inspiratory muscles are involved. The abdomen is 
protruded, and after a few seconds there is a forced 



146 NOTES ON PHYSICAL DIAGNOSIS 

inspiration, and the attack passes off. Etiological 
diagnosis : If the lungs are free between the attacks, 
then all conditions (emphysema, chronic bronchitis) 
can be excluded as causes. The upper air passages 
must be examined for polypi, etc. If nothing is found 
here, the abdominal organs must be examined, as 
worms, diseases of the uterus, stomach, etc., may pro- 
duce asthmatic attacks. Asthmatic attacks come in 
some women during menstruation. All those things 
that cause cardiac asthma must be thrown out, as 
lead poisoning, distended stomach, nephritis. Per- 
sonal idiosyncrasy to odors must be ruled out. Le- 
sions of the vagus nerve, as pressure from lymph 
glands or struma in the neck, etc., chronic diseases 
as malaria, arthritis, anaemia and infectious diseases 
must be considered. 

Atelectasis: Where air is not in the alveoli, and the 
walls lie against each other, there is a decrease of the 
functionating space and dyspnoea and cyanosis result. 
The edges of the lung are normal, and the retraction 
is made up by a compensating emphysema. If an 
area more than five centimeters is involved, a dull 
note may, by light percussion, be obtained which is 
at times hyperresonant. If the compression is com- 
plete there is bronchial voice and breathing. The 
crepitant rales over the area are characteristic, and 
show that the part can expand. With a deep nega- 
tive pressure in the thorax, there is decreased ex- 
pansion of the chest, also of the lung. Blood is not 
pumped into the right heart, and the decreased move- 
ment of the lung does not draw it from the right 
ventricle. The left auricle does not dilate, and so one 



DISEASES OF THE PEEURA AND LUNGS i47 

gets a venous and pulmonary congestion and low 
arterial pressure. Dilatation of the right heart is dis- 
tinctly made out as the lung edges are retracted. 
The diagnosis is made by noting the cause of the 
atelectasis, and by the absence of general symptoms 
which accompany other pulmonary affections. Etio- 
logical diagnosis: Exclusion of that variety found in 
the new born due to a lack of power to expand the 
lungs or to plugging of the bronchus with mucus or 
meconium. Atelectasis is secondary to other condi- 
tions, such as those which decrease the negative 
pressure in the thorax or compress the lungs, such 
as enlarged heart, aneurysm, tumors of the medi- 
astinum and pleura, exudates of air or fluid in the 
thorax, spinal curvatures, pressure upward of dia- 
phragm, from enlarged liver, spleen, ascites, gas, tu- 
mors, etc. The condition may arise from decreased 
expansions of the lung in very weak people or those 
lying on one side for a long time, also in capillary 
bronchitis of children and in typhoid, where the 
bronchi are plugged with mucus. Never make the 
diagnosis of atelectasis unless you have a cause. 
Pleural exudates have no increase in voice or fre- 
mitus. Pneumonia is more lasting and constant, and 
gives a bloody sputum and fever. By changing the 
position of the patient and having him breathe deeply 
the signs of consolidation change to normal if atelec- 
tasis is present. Local atelectasis must be diagnosed 
with care. Only when conditions for the production 
of atelectasis are present and continued crepitant 
rales are heard should the diagnosis be made. 

Hypostasis: As in atelectasis the mechanical role 



148 NOTES ON PHYSICAL DIAGNOSIS 

plays a large part in this condition. The lowest point 
of the lung is the seat of the lesion, but the position 
of the patient greatly influences the location of the 
stasis. Besides the collapse of the lung, we have an 
exudation of serum and blood cells due to the weak- 
ness of the heart, associated with superficial breath- 
ing. The conditions that favor the last are weakness 
from age, infectious diseases, especially typhoid and 
cachexia. All those conditions that decrease the size 
of the lungs, thus slowing the blood flow through the 
same, favor this condition, as ascites, meteorism, tu- 
mors, shallow breathing and large liver. The latter 
produces right-sided atelectasis. Usually, however, it 
is on both sides. The symptoms are dyspnoea, small 
pulse, dilated right heart, venous congestion and 
cyanosis (symptoms which go with many conditions, 
but in this condition are important). The early physi- 
cal signs, i.e., before all the air is out of the lung, are 
hyperresonance or dulness, feeble breath sounds and 
rales. Later when the air is all out the signs are 
those of complete consolidation. If the process goes 
on to inflammation, of a catarrhal or loose fibrinous 
pneumonic type, fever develops (if not already pres- 
ent from the original disease), and there is blood in 
the sputum. The last may be due to a bronchitis 
causing hypostasis. If the sputum is frothy and se- 
rous there may be many moist rales at the base to- 
gether with oedema. Hemorrhagic infarct is usually 
unilateral, and not so extensive, and there is marked 
heart weakness or a cardiac lesion present. 

Emphysema : Chronic lasting dilatation of the alve- 
olar wall with loss of elasticity and rupture of the 



DISEASES OF THE PLEURA AND LUNGS i49 

same, with fatty degeneration and obliteration of the 
capillaries and increase in the size of the lung and dis- 
placement and covering of organs by the same. Ex- 
piration is due to the faUing and sinking of the thorax 
by its weight and elasticity and the elastic traction of 
the lungs. In emphysema this is changed, and w^e 
have an expiratory effort or expiratory dyspnoea. In- 
spiration suffers first, as the lungs do not go to full 
expiration, and as the act is delayed, the reflex stimu- 
lus to the inspiratory centre is delayed. The chest, 
lungs, etc., are in the inspiratory position, and the 
ribs, cartilages and ligaments get stiiT and bony. In 
emphysema the lung is larger than normal, and 
oxygen in greater quantity is required to keep this 
residual air in a proper condition. Dyspnoea there- 
fore results. The above all cause a forcible inspiration 
by means of the accessory muscles. The diaphragm 
being flattened, does not rise on expiration or sink 
on inspiration, and is greatly hindered in its function. 
The abdominal type of respiration is lost, and one gets 
pure costal breathing. In this forced expiration in or- 
der to push up the diaphragm and to pull down the 
thorax, the spine is bent forward and may become 
fixed in that position. The vital capacity is reduced 
to I, GOO cc. and under. The frequency of respiration 
is increased, and one gets asthmatic attacks if there is 
constriction of the bronchi. In coughing the lungs 
go in the direction of least resistance over the heart 
and through the opening over the clavicles, which 
bulge. 

Physical Findings: The chest may be normal in 
shape, in the early stages, and if there is no cough, or 



I50 NOTES ON PHYSICAL DIAGNOSIS 

if the disease sets in after anchylosis of the cartilages, 
ligaments, etc., has taken place, the chest may be 
broad transversely, but more frequently antero-pos- 
teriorly. Due to the forced expiration and cough, 
the lower part is constricted and the upper part 
bulged, as the air is forced up to that part, it being 
more yielding than the lower. Fremitus may be nor- 
mal if the thorax is not too stiff and bronchitis is not 
present. 

Percussion: A hyperresonant note due to the re- 
laxed lung tissue is obtained. The edges of the 
lung are lower than normal, even extending to the 
first or second lumbar vertebra. The lung moves lit- 
tle on deep inspiration. The liver is depressed, the 
spleen likewise. (May be enlarged from congestion.) 
The spleen is not palpable, as it is not depressed by 
the immovable diaphragm. The upper dulness is 
lower than normal. 

Auscultation: The breathing sounds are less in- 
tense, expiration is prolonged, and, if bronchitis is 
present, harsh breathing and mucous rales are heard. 

Circulatory Disturbances: These are not the least 
important. B}^ the decreased elasticity of the lung 
and the diminished excursion of the thorax and lung, 
there is less elastic pull on the left auricle, and the 
blood is not drawn out of the lung capillaries in in- 
spiration. On expiration there is less negative press- 
ure in the thorax, so that the blood does not flow 
from the lung into the auricle, which is compressed. 
Numbers of capillaries in the lung are destroyed or 
narrowed, and the lung does not expand enough to 
draw blood from the right ventricle, so that there 



DISEASES OF THE PLEURA AND LUNGS 151 

is not only hypertrophy of the ventricle from the first 
cause, but also dilatation from the second. As the 
lungs do not move and expiration is prolonged and 
forced, the blood is not only not drawn into the tho- 
rax as normally, but is retarded greatly by expira- 
tion, which latter condition is ag'g^ravated by the 
coughing. So we have a retardation of the blood flow 
through the systemic veins, a high blood pressure in 
the pulmonary arteries, and a low one in the pul- 
monary veins. The systolic emptying of the left 
ventricle is aided by the normal expiration, and re- 
tarded by forced expiration. All these go to decrease 
the flow of blood into the aorta, and thus lessen the 
blood pressure. It is at times impossible to demon- 
strate a right heart enlargement, as the heart is not 
only covered by the lung, but by the low position of 
the diaphragm, the base of the heart is displaced 
downward and backward, and the apex outward. 
The apex cannot be seen or felt, and percussion gives 
a smaller heart flatness than normal. If one gets a 
normal-sized area of flatness in emphysema, a large 
heart is suggested. Marked epigastric pulsation can 
be felt and seen due to the low position of the dia- 
phragm, and a hypertrophied right ventricle. A sys- 
tolic retraction of the epigastrium can be seen due 
to atmospheric pressure. The auscultatory signs of 
the heart vary usually, in that the first sound at the 
apex is faint due to the covering of the lung. It may 
be reduplicated or sharp from myocarditis. The sec- 
ond pulmonic sound is accentuated, but may be nor- 
mal due to the lung covering. The aortic is weak or 
absent. Murmurs are usually heard which are acci- 



152 NOTES ON PHYSICAL DIAGNOSIS 

dental. If relative tricuspid insufficiency is present, 
one gets a venous pulse, etc. Signs of venous stasis, 
cyanosis, and oedema follow. The bronchitis grows 
worse with the weakness of the heart, as the bron- 
chial veins are congested. Cough and expectoration 
increase, and if blood be present in the latter, tuber- 
culosis and emboli are to be thought of. 

Differential Diagnosis: The form of thorax, char- 
acter of breathing, revelations of percussion, such as 
character of note, size of lungs, diminished excursion 
and absence of heart flatness, together with an en- 
larged right heart and signs of blood stasis with an 
accentuated pulmonic second sound, together with 
a displaced liver and spleen, are all characteristic 
features. Acute distension of the alveoli in asthmatic 
and capillary bronchitic conditions may be difficult 
to detect, where no history is obtainable. The 
lungs in these conditions are never greatly en- 
larged, and as soon as the acute symptoms subside 
return to their normal size and mobility. Pneu- 
mothorax has in common only the feeble voice 
and fremitus and the loud percussion note. All the 
other symptoms are different. \A'ith pulmo excessi- 
vus, where the lungs are very large, one gets the same 
percussion note as in emphysema, and enlargement 
of the lung with absence of heart flatness. However, 
the lung edge has normal excursion, and there is no 
weakness of voice, fremitus and breath sound, and the 
pulmonic second sound is not accentuated, or the 
right heart enlarged. Brown Induration : In mitral 
disease and idiopathic hypertrophy with left heart 
failure, the diagnosis is far from easy. In em- 



DISEASES OF THE PLEURA AND LUNGS i53 

physema the characteristic form of the chest may 
be absent and marked signs of venous congestion 
with heart murmurs be present, while in heart dis- 
ease, the lungs may be enlarged and the bronchi- 
tis may be marked. Hydrothorax may be present 
and interferes with the marking out of the lungs, 
and hydropericardium may be mistaken for a large 
heart. The change of position of patient does not 
indicate hydrothorax, as the fluid may not change, 
due to adhesions, and the lung may from com- 
pression be unable to inflate. Heart disease and 
emphysema in some cases are associated. Tubercu- 
losis and emphysema are not infrequent. Early 
stages of emphysema are hard to diagnose, but with 
the slight increase in the size of the lung with the 
distinct decrease in mobility and the other symptoms 
a probable diagnosis can be made. 

Vicarious Emphysema is where the air does not 
enter one portion of the lung, the normal portion be- 
ing distended, not only by inspiration, but by expira- 
tion, coughing and straining. It is seen in pleural ex- 
udates, fibrosis, scoliosis, and in lung retractions after 
pleurisy. The diagnosis is based on the etiological 
factor. The sound lung is larger than normal and 
extends over on to the diseased side. If a part of 
the lung is fibrous, the normal part can distend so 
that the edges of the diseased lung are normal in 
size. 

Senile Emphysema is an atrophy of the alveolar 
wall with no distension. The lungs are not enlarged 
and the edges are movable. The heart is not cov- 
ered. The sides of the chest are flattened. Dyspnoea 



154 NOTES ON PHYSICAL DIAGNOSIS 

is present, due to the decrease in the alveolar surface 
and the destruction of the capillaries. Therefore 
there is venous stasis. The heart is not enlargfed to 
the right as this organ takes part in the general 
atrophy. There is nothing common between the 
two conditions, save the dyspnoea and cyanosis. 

Interlobular Emphysema has more pathological than 
clinical interest, due to the marked coughing and 
straining. 

Siihpleiiral and mediastinal Emphysema is air in the 
skin of the neck, back and chest wall. Replacement 
of the heart flatness with a sonorous note that is 
distinguishable from pneumopericardium in that it 
does not vary on changes of position. This is due 
to the air in the anterior mediastinum. One gets 
crepitant rales with the heart movements and ab- 
sence of cardiac pulsation. There is resonance to 
the edges of the ribs with an absence of breath 
sounds. Attacks of suffocation and distension of 
the veins in the neck occur. 

CEdema of the Lungs may usually be readily diag- 
nosed. In extreme cases the lung may be so com- 
pletely infiltrated with serum that one gets all the 
signs of consolidation, but this is very rare. Usually 
there is no change in the percussion note from the 
normal, unless the interalveolar tissue is infiltrated 
with serum, when we get a hyperresonant note. By 
auscultation many very moist rales are heard of 
varying sizes but always having a fluid character. 
The sputum is usually copious, foam-like and tinged 
with blood, especially in pneumonias, where it is 
brown in color, coming as it does from the deeper 



DISEASES OF THE PLEURA AND LUNGS i55 

parts of the lung. The above makes the diagnosis 
sure, unless the condition is very small and local, or 
if in those unable to expectorate. In this case the 
tracheal rattle or the retained sputum masks the 
finer auscultatory signs. To find out the cause of 
the oedema is the chief point in the diagnosis, as the 
oedema is but a result of some other condition. 
There are two forms of oedema, the inflammatory 
and the passive congestive. In the first, there is an 
inflammation of the alveolar wall, intense enough to 
cause extravasation of serum, but not of cells. This 
condition is seen outside of the areas of true con- 
solidation in pneumonia. Is also seen where the 
whole lung is involved without any true cellular in- 
filtration. This may be due to the fact that the pa- 
tient dies at an early period of exudation, when the 
serum has come out, but the cells have not started 
to infiltrate. According to Sahli, the inflammatory 
character of the oedema is to be met with more fre- 
quently than is thought. The signs in this form are 
those of oedema with some signs of true inflamma- 
tion scattered about or of a primary true pneumonia. 
The passive congestive form has been worked out by 
Welch and Cohnheim. Paresis of the left ventricle 
may occur, which causes a backing of the blood into 
the lungs, while the right ventricle keeps up its con- 
tractions. The cause is still the same, but in these 
cases the heart may have been doing more work 
than normally during the patient's life, such as we 
see in interstitial nephritis or arteriosclerosis. When 
this excessive function fails a damming back of the 
blood immediatelv occurs, and a continuance of the 



156 NOTES ON PHYSICAL DIAGNOSIS 

right heart action with oedema. Lack of oxygen has 
the effect of inhibiting the function of the left heart 
as compared with the right. The reason that this 
condition does not happen more often in vakailar 
disease of the heart is that the right heart fails as 
well as the left and there is no high tension in the 
pulmonary vessels. In resistance to the pulmonary 
circulation, the right heart overcomes this and the 
left heart throws the proper amount of blood into 
the arteries. In these cases not the left but the 
right heart fails, and oedema results. Spasm of the 
heart as in angina pectoris can produce c^edema in 
the same way, as the spasm involves the left heart 
more than the right (Grossmann). The essential 
conditions for the production of oedema of this sort 
is the failure of the left heart to throw out the proper 
amount of blood into the arteries, together with the 
strong contraction of the right ventricle. 

Lobar pneumonia is usually an easy diagnosis when 
signs of infiltration are prominent. It is only when 
the infiltration is local or small in extent that the 
diagnosis is difficult. The most important symp- 
tom is the rust-colored sputum, and only in ex- 
tremely rare cases does the expectoration fail. 

The sputum is tough, sticking to the cup, trans- 
parent; blood is mixed with it and the color is yellow 
or brown red. When put in water branched coagulse 
of the finer bronchi may be seen, later when resolu- 
tion sets in the sputum is yellow and in delayed 
crisis green with abundance of pus cells. With in- 
flammatory oedema it is foamy and prune colored. 
With gangrene, it has the characteristic odor. Mi- 



DISEASES OF THE PLEURA AND LUNGS i57 

croscopically it is made up of altered red cells, 
mucous bodies and white cells, epithelium and micro- 
organisms. Friedlander's bacillus is met with only 
exceptionally. Fraenkel's is by far the commoner 
organism in pneumonia. The bacteria are most viru- 
lent when taken from the lung at the time of great- 
est inflammatory reaction. In the cases of marked 
toxemia it has been found in the blood. Fraenkel's 
bacillus can migrate to other organs than the lung 
in pneumonia. It is also found in other organs in 
other diseases than pneumonia. The streptococcus, 
usually of the broncho-pneumonic type, can cause a 
lobar pneumonia. In this type of pneumonia the 
resolution is markedly delayed. There are numbers 
of mixed infections. When the sputum is typical, 
there can be no doubt as to the diagnosis, though all 
physical signs fail. However, the signs usually ap- 
pear early, and often on the first day. AMien the 
signs are indistinct, the consolidation being very 
small and central, the area can be discovered only 
by a slight increase of voice or dulness as compared 
with the corresponding sound side. The voice 
change is the earliest, as the diminished breath 
sounds described by some are not constant. Usu- 
ally this first change in voice is heard directly in the 
axilla or over the scapula. Percussion in the stage 
of engorgement and resolution gives hyperreson- 
ance. Over the consolidation one gets dulness, but 
never so intense as that obtained over fluid. Usually 
this is sharply limited to the area involved. 

The cracked-pot note has been obtained and if 
the apex is consolidated Williams' tracheal note. 



158 NOTES ON PHYSICAL DIAGNOSIS 

with the change on opening and closing the mouth, 
can be demonstrated. When the lower left lobe is 
involved, one gets the tympany of the stomach, but 
the half moon space is never obliterated as in pleural 
exudate, the solid lung not passing into the comple- 
mental space. Inspection gives increased breathing 
and expansion of the sound side. There is dimin- 
ished expansion on the involved side early if pleurisy 
is present.^ The involved half of the chest is larger 
than the other, but never so great as that seen in 
pleural exudate. 

Palpaticn gives increased fremitus, if consolidation 
is present and lies close to the chest wall. It is not 
obtained in very large infiltration where the chest 
is too distended to vibrate; also if the large bronchi 
are plugged with mucus. 

Auscultation gives bronchial voice over the con- 
solidation and aegophony if the consolidation is very 
great and the bronchi are compressed, the vibration 
passing through the compressed and filled bronchi 
irregularly. Crepitant rales are heard at the early 
stage till consolidation sets in. They come at the 
end of inspiration and are rarely if ever heard on 
expiration. In the latter case, pleuritic rales and 
fine bronchial rales must not be overlooked. Mu- 
cous rales in the bronchi of the consolidated area 
may have a "metallic timbre." 

The general symptoms are ushered in by a marked 
chill, sometimes several slight chills, rarely no chills, 
save in old people. Pain in the side if pleurisy is 
present,"^ pain in the abdomen and along the attach- 

* Primary pleurisy is rarely complicated with pneumonia. Pneu- 
monia practically never occurs without pleurisy. — Editor. 



DISEASES OF THE PLEURA AXD LUXGS i S9 

ments of the diaphragm. In this latter case no 
physical signs are present at all. Breathing is rapid 
and rises above the pulse rate showing that it is not 
due to the temperature alone. It is always above 
30 and can go as high as 100. (Gerhardt.) The 
temperature rises to or above 104 degrees Fahr. very 
quickly. It may fall on the first or second day, but 
this is very rare ; usually it lasts a week. Just before 
the crisis, one may have a fall of temperature ( pseudo 
crisis) followed by a rise, or the temperature may 
rise very high with no pseudo crisis before the fall. 
After the fall there may be a subnormal temperature 
for awhile. The intermittent height of fever in pneu- 
monia is seen when new areas are suddenly involved 
or the disease is complicaetd with malaria. Old 
people often have no fever. 

The pulse is usually full, strong and fast and with 
cardiac failure becomes more accelerated and irregu- 
lar. Heart weakness and collapse is seen after the 
crisis. Cough is superficial and restrained, i.e., short 
cough raises little but sounds very loose. In old 
people it may be absent. 

The face at first shows the flush of fever, followed 
by cyanosis and herpes labialis, which is very fre- 
quent. Jaundice is a frequent symptom, and all 
cases with this color of the skin and high fever 
should have the lungs examined for pneumonia. 
The spleen is enlarged but is hard to palpate, es- 
pecially if the left side is involved, as the diaphragm 
does not descend. Percussion is very untrustworthy. 
The enlargement of the spleen is greater after the 
crisis, and this may be due to its function of accu- 



i6o NOTES ON PHYSICAL DIAGNOSIS 

mulation of waste material. This post critical swell- 
ing is greater the earlier the crisis. 

The urine shows changes due to the fever, but al- 
buminous urine is more constant than in any other 
infectious disease and at times the degeneration of 
the kidneys passes on to an acute nephritis with 
marked albuminuria, blood cells and kidney epithe- 
lium, which nephritis may last for months after the 
acute disease. During the height of the fever there 
is an increase in the albumpse due to the destruc- 
tion of the nuclei of the leucocytes and a decrease 
in the chlorides, which latter reappear as soon as 
the inflammatory symptoms have subsided. The ex- 
cretion of urates is increased throughout but especi- 
ally at the time of the crisis. This latter may have 
some relation to the diaphoresis that takes place at 
the time and the destruction of the nuclei. There 
is a distinct increase in the urea during resolution 
and for one or two days the urine may be alkaline 
(Pick). Albuminuria may be due to cardiac weak- 
ness. 

The blood shows an acute leucocytosis more than 
in any other disease. The destruction of the red 
cells varies with the intensity of the inflammation. 
Pneumococci may be found in the blood. 

As a rule the diagnosis is easy. Those cases in 
which the signs are late in appearing, and expectora- 
tion is absent, or an associated condition is present, 
as delirium tremens, are less readily diagnosed. In 
old people, cough, high fever and chill may be ab- 
sent, but usually the physical signs are distinctive. 
The abortive form (Kiihn) in epidemics with all 



DISEASES OF THE PLEURA AND LUNGS i6i 

symptoms of pneumonia and no signs and of short 
duration may occur. These sometimes have purely 
cerebral symptoms. They should be diagnosed as 
pneumonia only with caution and after every cause 
has been excluded and an epidemic is present. 

Differential Diagnosis: In pneumonia, the true 
signs of consolidation are distinct and the dulness 
is less intense than in pleurisy with effusion. In the 
latter the signs of consolidation are greatest above 
the fluid and diminish as one passes into the dullest 
area below. With a pneumonia of the upper part of 
the lower lobe and with some oedema or infiltration 
below, one gets the same signs as in pleurisy with 
effusion, save that the rales are heard below, whereas 
in pleurisy with effusion they are at the upper part 
of the dulness. The termination of the two condi- 
tions is distinctive. Infarct may begin with a chill 
and fever. In this case the signs are the same; the 
sputum is more intimately mixed with blood and 
there is a cause present. The fever is not t3^pical, if 
present at all. CEdema is difficult to differentiate, 
especially the inflammatory variety, besides, the two 
conditions frequently exist side by side. The onset, 
exciting cause, heart action and the foamy sputum, 
together with the diffuseness and bilateral distribu- 
tion, point to oedema. A true serous pneimionia oc- 
curs which is discussed under oedema. Tuberculosis 
of the rapidly advancing pneumonic variety simulates 
the acute pneumonia. The sputum is not the same 
and the tubercle bacilli are present, and the his- 
tory aids one. However, an acute pneumonia added 
to a tuberculous process ma}^ mask the latter, and 



i62 NOTES ON PHYSICAL DIAGNOSIS 

only after studying the cause of the disease is a 
diagnosis possible. 

Catarrhal Pneumonia: The diagnosis is made on 
the symptoms, cause and history, rather than on 
the physical signs, save that the negative results 
of the latter, together with the symptoms, etc., re- 
ferrable to an acute pulmonary condition are of 
value. The disease is caused by the extension of 
a bronchitis (either direct or by aspiration) to the 
alveoh, the diplococcus of Fraenkel usually being 
the excitant. Atelectasis plays an important part 
in that it prepares the way for the extension. Chil- 
dren with their small bronchi (which readily become 
plugged), delicate mucous membranes and suscep- 
tible alveoH, taken together with their inability to 
expectorate, are prone to the disease. In the old, 
the conditions are not the same, but here there 
is not only lack of power to expectorate, but also 
a diminished excitability of the bronchial mucous 
membrane with an absence of cough stimulation. 
Also these people have an atrophic mucous mem- 
brane with a loss of the ciliated epithelium which 
normally sweep the secretions out of the small 
bronchi. All these factors favor infective material 
passing to the alveoli and producing pneumonia. 
(N.B. — x\trophy of the muscle tissue of the bronchial 
wall may here be a factor). Aspiration pneumonia, 
and infectious bronchial catarrh are the most fre- 
quent causes, such as accompany influenza, measles, 
whooping cough, diphtheria, scarlet and typhoid. 

Differential Diagnosis: Croupous pneumonia has a 
sudden onset, usually unilateral and local; is not apt 



DISEASES OF THE PLEURA AND LUXGS 163 

to be preceded by an infectious bronchitis and comes 
in active adults. The sputum is often absent in 
bronchopneumonia, but when present is usually puru- 
lent. Exceptions to these are frequent. 

^^'ith absence of signs save fine mucous rales, 
broncho-pneumonia is impossible to differentiate 
from acute miliary tuberculosis. The location of the 
signs at an apex and the finding of the bacilli may 
help, but both conditions are more often absent. 
Choroid tuberculosis points toward general tubercu- 
lous infection. Atelectasis : The signs change or dis- 
appear on alteration of the patients' position and 
there usually is no fever. 

Interstitial Pneumonia: Usually follows a chronic 
inflammatory process or is the result of a reparative 
process following acute inflammation or destruction 
of lung tissue. It is seen after chronic bronchitis, 
pleurisy of gangrenous or caseous processes after 
lobar or catarrhal pneumonia, and where the alveolar 
wall is thickened. As a sequence to syphilis and to 
the inhalation of coal, stone or iron dust, etc. In 
making a diagnosis the aetiology must be taken into 
account. The signs vary with the extent of the pro- 
cess. 

On inspection one sees a retraction and immobil- 
ity of a part or whole of one side of the thorax. 
The ribs lie close together, the spine is curved to- 
ward the diseased side, the shoulder is lower, and 
the scapula, although closer to the spine, flares out- 
ward. The respiratory movements are decreased 
and the involved half has a smaller measurement 
than the sound. The capacity of the lungs is de- 



1 64 NOTES ON PHYSICAL DIAGNOSIS 

creased. In contractions of the left lung, the apex 
of the heart is displaced to the left and upward, due 
to the negative pressure or traction. The pulsation 
in the cardiac area is greater, as the lung is retracted. 
Just outside of the pulmonic area a systolic pulsa- 
tion can be seen and felt at times; also a diastolic 
shock of the pulmonic second sound, which is ac- 
centuated in this condition. In the rig*ht sided con- 
tractions the picture is different. The heart is dis- 
placed to the right and by vicarious emphysema of 
the left lung the heart flatness is absent. The dis- 
placed abdominal organs and the movements of the 
lateral halves of the diaphragm must be observed. 

Percussion: If the lesion is at the upper part of the 
lung, the apex is lower than normal and the signs 
of phthisical or bronchiectatic cavities may be pres- 
ent. If the lesion involves the lower part of the 
lung, the lower border is higher than normal, carry- 
ing with it in its upward retraction the diaphragm 
and the abdominal organs, unless the pleura is ad- 
herent or there is a marked decrease in the expansion 
of that side of the thorax. By vicarious emphysema 
(the middle lobes being the seat of the lesion) the 
edge of the lung may be as low as normal, but have 
decreased excursion. The uninvolved lung may be 
so emphysematous that it reaches over into the in- 
volved half of the thorax, and if movable this linear 
movement on the anterior edge can be demonstrated 
by percussion. This is especially noticeable in left 
sided contractions. 

Auscultation: One gets bronchial voice and fre- 
mitus, bronchial breathing and ringing rales. If cav- 



DISEASES OF THE PLEURA AND LUNGS 165 

ities be present, all the characteristic signs are ob- 
tained. Over other parts of the lung one gets signs 
of emphysema. 

The sputum may contain the exciting dust par- 
ticles. If bronchiectatic cavities be present, the char- 
acteristic periodic expectoration and the signs are 
present. Blood is usually absent. When present, 
tuberculosis should be suspected. Circulatory dis- 
turbances are due to the destruction of the lung tis- 
sue, and the decreased expansion of the lung with 
consequent right heart dilatation and venous conges- 
tion. 

Chronic Pulmonary Phthisis: This is a destructive 
disease of the lung with progressive characteristics, 
as apical catarrh, tuberculous granulations, tubercu- 
lous peri-bronchitis, cheesy bronchopneumonia, and 
finally cavity formation. All these pathological 
changes may be traced clinically in their develop- 
ment. The presence of the tubercle bacillus indicates 
the chronicity or subacuteness of the process. 

The Diagnostic Value of the Tubercle Bacillus: In 
most of the cases it is easy to find. In early stages 
or in the fibroid stage, they may be absent or only 
found after twenty or thirty examinations. The num- 
ber has no relation whatever as to the extent of the 
process. Physical signs can alone tell this, and also 
give an idea where and in what stage the process 
is. It must be remembered that tubercle bacilli 
may be in the sputum of a patient with tuberculosis 
of the nose, etc. An absolute diagnosis cannot be 
made unless the bacilli are found. The smegma 
bacillus (decolorized with alcoholic methylene blue) 



1 66 NOTES ON PHYSICAL DIAGNOSIS 

and the lepra bacillus (not transmissible to animals) 
are morphologically and in their staining qualities 
similar — the latter is identical in these respects to the 
tubercle bacillus. The mixed infections, such as 
streptococci, staphylococci and diplococci add greatly 
to the symptoms and the gravity of the prognosis. 
The use of tuberculin causing an active reaction of 
the tuberculous process locally with general manifes- 
tations, also is a dangerous practice."^ It is by no 
means sure, as many tuberculous processes give no 
reaction whatever. 

Diagnosis of tlie First Stage: The disease is intro- 
duced in conditions of weakness, anaemia, diabetes, 
poor nourishment either from poor food or blood or 
from gastroenteritis. Follows inflammatory diseases 
of the bronchi or lung tissue, but rarel;y, if ever, fol- 
lows lobar pneumonia. The apex of the lung is the 
most frequent site of the lesion, and this is due (ac- 
cording to Hanan) to the act of coughing, which 
drives the infection up into the apex or back from the 
bronchi, t The first sign is rales, indicating a local 
catarrh at the apex. All other signs may be absent. 
One usually has slight dulness, also above the clav- 
icle, and the bacilli may be found in the sputum. In 
percussion of the apex, the difference in note of the 
two sides should not be taken into account, as this 
difference is frequently met with in normal individ- 
uals, and especially in emphysema. Only distinct 

* At Saranac Dr. Trudeau uses this method for diagnostic pur- 
poses and reports no ill results. It should not be employed, however, 
by those unfam'liar with the method and proper usage. — Editor. 

\ That it is an area of respiratory inactivity is another explanation. 
— Editor. 



DISEASES OF THE PLEURA AXD LUXGS 167 

changes in the note with marked differences in the 
height of the apex above the clavicle, together with 
auscultatory changes should be recognized. The 
breathing is diminished. These may be cogwheel or 
prolonged expiration, with a sharp or rough vesicular 
murmur. Undetermined breath sounds together with 
fine mucous or medium-sized mucous or crepitant 
rales may be present. Hemorrhage precedes the 
tuberculous lesion only in those cases where it is 
induced by trauma, the blow causing the hemor- 
rhage, and the blood acting as a culture medium for 
other bacteria which set up an inflammation, thus 
predisposing this part of the lung to tuberculous in- 
fection. This is extremely rare. Usually the hemor- 
rhage comes from a small process in the smallest 
bronchi, where the wall is involved. The hemor- 
rhage occurs in people apparently normal, and is fol- 
lowed by a rapid increase of the signs. This increase, 
in the extent of the process after the hemorrhage, is 
particularly noticeable when the process has extended 
to small cavity formations, and the contents of the 
same mixed with blood is aspirated into great areas 
of the lung. This is followed by a difluse acute pro- 
cess with death in two or three weeks (Baeumler). 
Such hemorrhages follow straining, and the signs at 
first are crepitant rales, high fever and a tympanitic 
note. This differs from miliary tuberculosis in that 
the course is more rapid, blood and tubercle bacilli 
are found in the sputum and signs of consolidation 
set in early. AA'ith all the above symptoms fever is 
present. It is rarely absent in tuberculosis. A high 
fever indicates a rapid process or an extension, com- 
plication, etc. 



1 68 NOTES ON PHYSICAL DIAGNOSIS 

The diagnosis is supported by .the family history, 
weakness, etc., the shape of the chest, the poor con- 
dition and the weak muscles, the presence of tuber- 
cular glands, bones, joints, or anal fistulse. 

Combinations of Tuberculosis and Pleurisy: Fre- 
quently the pulmonary tuberculous process is intro- 
duced by pleurisy. The pleurisy is really a manifesta- 
tion of the tuberculous process in the lung, which 
later develops rapidly after the pleurisy is cured, or 
during the acute stage. Frequently a patient who has 
a latent tuberculous process becomes ill through the 
addition of pleurisy, and the process is discovered. 
Pleurisy that is primary usually involves the sound 
side, and the coughing, etc., together with the run- 
down condition of the patient, predisposed to the in- 
fection of the good lung. The tubercle bacilli in the 
sputum may be found in cases that give no physical 
signs. 

Diagnosis of tlie Second Stage: ■ This is character- 
ized by peribronchitis and cheesy pneumonia. This 
stage is usually combined with that of the third stage. 
At times the patient dies before softening of or dis- 
charge from the area, and the lung gives a picture of 
true broncho-pneumonia. 

A ver}^ rapid process with cavity formation is met 
with and is called pJitJiisis Uorida. At times every 
change can be found in the same lung, even to fibrous 
formations. 

Percussion gives marked dulness from the apex 
downward together with bronchial voice and fremi- 
tus, mucous rales and bronchial breathing. Usually 
these signs are most marked at the apex and decrease 



DISEASES OF THE PLEURA AXD LUXGS 169 

as one descends. In those cases of gelatinous cheesy 
broncho-pneumonia (of A. Fraenkel and Troje) the 
material is aspirated into the lower part of the lung. 
In these cases one gets signs most distinct at the 
bases AA'ith remittent fever, prostration, green or 
bloody sputum with very few tubercle bacilli. If the 
connective tissue process predominates, we then get 
retraction or diminshed expansion over the involved 
area, the lowering of one shoulder and all the other 
signs of interstitial pneumonia. Other symptoms 
referable to the lung are systolic murmurs over the 
subclavians due to narrowing of the vessel produced 
by the shrunken apex, paralysis of the right recurrent 
laryngeal nerve from the same cause and the eye 
changes due to involvement of the third cervical 
ganglion. The left laryngeal nerve is involved when 
the bronchial glands are enlarged. Pleuritic rubs are 
heard very often and may be followed by an effusion. 
The skin may show pityriasis or lichen, and there may 
be cyanosis, right heart complications, night sweats, 
etc. The fever is variable, and follows no constant 
rule. Some cases have no fever, while others have a 
constant high temperature. The heart is usually not 
enlarged, as it adapts itself to the decreased amount of 
blood in the system, besides, no hypertrophy is apt to 
set in on account of the lowered vitality of the organ- 
ism. Xow and then cases are met with which show 
distinct right heart dilatation and hypertrophy, with 
accentuation of the pulmonic second sound. In 
marked fibrous conditions the heart is displaced and 
congestion of organs may be shown by enlarged liver 
and spleen. These latter organs can enlarge of them- 



lyo NOTES ON PHYSICAL DIAGNOSIS 

selves (as fatty liver and hypoplastic spleen). The 
urine is decreased from the congestion and changes 
within the kidneys. The sputum in the third stage 
is profuse, muco-purulent with alveolar cells and bac- 
teria of all kinds together with the tubercle bacilli. 
If a gelatinous pneumonia be present, one gets a 
greenish sputum or a sputum similar to that of lobar 
pneumonia. 

Diagnosis of the Third Stage: This stage is charac- 
terized by softening of the consolidated areas and 
their exudate leaving cavities. The sputum be- 
comes tough and heavy (sinking in water) and not 
frothy. This is due to the fact that it lies in the cavi- 
ties and becomes concentrated and then is expelled 
direct, with no chance of mixing with air. It contains 
many elastic fibres. Blood in the sputum may appear 
in streaks or in large quantity. This may be due to 
the process involving the blood vessels in the lung 
or to rupture of an aneurysm. Death may follow a 
profuse hemorrhage from a large cavity. Bacteria 
and tubercle bacilli are found in great numbers. 
Aside from the general symptoms and the above, the 
physical signs give definite data if the cavity is acces- 
sible, i.e., not deep-seated or hidden by consolidations. 

Percussion: Tympany at the apex above or below 
the clavicle indicates cavity. The cavity must not he 
smaller tJian a zcalniit, lie close to the thorax or be sep- 
arated from it by consolidated tissue, and the walls 
must be in a condition to vibrate to give this sign. 
The distinctness of the tympany is dependent on the 
quantity of air within the cavity, z.e., there must not be 
too much secretion. In large cavities Wintrich's sign 



DISEASES OF THE PLEURA AND LUNGS 171 

can be obtained, i.e., a high note results on percuss- 
ing over the cavity with the mouth open, and a low 
one with the mouth closed, Avhile the patient stops 
breathing. Gerhardt's sign is also present, z.r., change 
of note in placing the patient on the back from the 
upright position. The so-called interrupted Wint- 
rich's sign is that which can be obtained in the upright 
position and not in the dorsal or vice versa. All these 
percussion phenomena can be obtained in other con- 
ditions of the lung. To be mentioned is Friedrich's 
sign, i.e., a slight change of note on inspiration and 
expiration. Leube states that when the above phe- 
nomena are definitely obtained they indicate cavities. 
If Wintrich's sign is absent, Rumfe's inspiratory 
change of note may be obtained, i.e., after two or 
three deep respirations, a final inspiration is taken 
and the mouth and nose of the patient closed. 
Then opening the mouth and protruding the tongue 
gives a change of note. The cracked-pot note is 
often obtained in normal people with thin chest walls 
while they speak. It is obtained over cavities which 
lie close to the chest wall and communicate with a 
bronchus. A metallic overtone lasting longer than 
the dull ground tone is obtained over large cavities 
with smooth, uniformly thickened walls which are in 
a condition to refiect the sound wave. This can only 
be heard at times by auscultating when one percusses 
with a hard substance. The opening to the bronchus 
must not be too large, and by opening the mouth 
the sound can be heard more distinctly. It is ob- 
tained frequently in pneumothorax. 

Auscultation: With the above conditions present, 



172 NOTES ON PHYSICAL DIAGNOSIS 

a metallic tone is added to the breath sound (amphoric 
breathing). The voice may be amphoric and mucous 
rales have a metalHc character. Falling drop or me- 
tallic tinkle due to mucous rales may be obtained. 
Pneumothorax can give all the signs of cavity, espe- 
cially if local. Usually in cavity the intercostal spaces 
are sunken and the fremitus and voice are increased. 
In local pneumothorax the opposite is true. Cracked- 
pot and other percussion signs are not so frequently 
met with in the latter condition. Pneumothorax is 
not often mistaken for cavity, as succussion rarely 
if ever occurs in cavity. Other symptoms as weak- 
ness and emaciation are increased. However, there 
are exceptions, as well nourished patients may have 
marked changes in the lung. 

The urine, aside from tuberculosis of the kidneys, 
etc., shows changes of degeneration or nephritis. 
The presence of the diazo reaction indicates a rapidly 
progressive process, and is a bad prognostic sign. 
Acute miliary tuberculosis may appear at any time. 

Note. — Tubercle bacilli from the lung of miliary tuberculosis are 
often not found, and this failure to find the organisms constitutes one of 
the most confusing negative findings in a disease which is frequently- 
confounded with typhoid fever and sepsis— i5"(-/zV^r. 



EMBOLUS OF THE PULMONARY ARTERY. 

HEMORRHAGIC INFARCT. 

Their origin is thrombi on the tricuspid valv€ 
from endocarditis or more often from thrombi 
formed in a dilated and weakened right auricle or 
ventricle as a consequence of obstructive pulmonar}^ 



DISEASES OF THE PLEURA AND LUNGS i73 

conditions, as emphysema, etc., or to mitral disease. 
It also results from left heart failure or even from 
right heart failure in myocardial degeneration. Un- 
less an origin can be found for the embolus, the 
diagnosis should be made with care. The closure of 
one of the large pulmonary branches or the pul- 
monary artery itself, leads to sudden death. The 
blood cannot pass to the left heart, so the arterial 
supply is cut off. The right heart cannot empty it- 
self, and therefore dilates, causing venous conges- 
tion. There is loss of consciousness, marked dysp- 
noea, and collapse. A paralysis of the heart may 
lead to the same symptoms and cases have been di- 
agnosed which at autopsy showed no signs of em- 
bolus. Dyspnoea is dependent on the size of the ves- 
sel obstructed and usually does not last long, as the 
organism soon accommodates itself to the condition. 
A chill is always present and fever if the embolus is 
infected in which case a pleurisy is set up and can 
even lead to abscess formation. The physical signs 
are those of brondio-pneumonia, located in the lower 
part of the lungs or along the spine. The sputum is 
usually bloody and other conditions, such as tuber- 
culosis, fibrinous bronchitis, purpura, and tumor of 
the lung must be excluded. In very rare cases, 
where the embolus has not completely closed the 
artery, a systolic thrill can be felt and a murmur 
heard over the area of embolism. Unless the etio- 
logical factor can be found, the diagnosis should not 
be made. There are some conditions, such as anas- 
tomosis of the pulmonary and bronchial vessels, 
where the embolus causes no infarct. If the emboli 



174 NOTES ON PHYSICAL DIAGNOSIS 

are infected, numbers of small metastatic abscesses 
are formed which produce no physical signs. If the 
embolus is large, a pulmonary abscess may form. 
The diagnosis must not be made till the etiological 
factor is discovered. 

Pulmonary Abscess. 

Usually follows septic emboli, alcohoHc lobar- 
pneumonia, inhalation broncho-pneumonia. It may 
also follow any pulmonary inflammation and is a 
frequent sequel of influenza pneumonia. The etio- 
logical factor is of the greatest importance and only 
when the symptoms are distinct can the diagnosis 
be made with ease. The sputum is usually made 
up of pure pus. After standing in a glass, the 
upper layer is clear, or turbid, and is composed of 
serous material, while the lower is made up of 
pus cells, elastic fibres in alveolar arrangement, 
fat cells and cholesterin and hsemotoidin crystals, 
besides bacteria of all kinds. After the discharge 
of the abscess the typical signs of cavity are 
present, which gradually disappear if the process 
heals. The case usually runs a septic temperature 
with chills. The differential diagnosis is to be made 
between the above condition, local empyema with 
rupture into the lung, tuberculous bronchiectatic cav- 
erns and pulmonary gangrene. The local empyema, 
whether from spinal, mediastinal or subphrenic ab- 
scesses, can be diagnosed by the fact that at no time 
of the disease can pulmonary tissue and structure 
be found in the sputum. In addition the local mani- 
festations of these conditions may aid. The phthisi- 



■ DISEASES OF THE PLEURA AND LUNGS iJS 

cal cavity does not furnish the same quantity of elas- 
tic fibres as- the abscess and the sputum is not so 
purulent or abundant. Tubercle bacilli are found in 
the sputum of all such cavities. The etiological fac- 
tors and history aid in the diagnosis. Tuberculous 
conditions may be present elsewhere. The site 
does not help, as abscess may form at the apex and 
a tuberculous cavity may occur in the lower lobes. 
More difficult is the diagnosis of bronchiectatic 
cavities. However, the sputum here is of a putrid 
odor, not so purulent, and contains few, if any, elas- 
tic fibres, and never an alveolar arrangement. In 
pulmonary gangrene, the elastic fibres are absent, 
due to their being digested by some peptic ferment. 
Only in gangrene following abscess are they found. 
The foul odor, dirty color, the Ditrich's plugs, lep- 
tothrix, coloring blue with iodine, and the cause of 
the disease, all are distinctive of the process. 

Pulmonary Gangrene. 

The diagnosis is easy, as the symptoms are char- 
acteristic. The sputum has a penetrative, sweetish, 
foul odor, which is most marked at the time of ex- 
pectoration. Long standing specimens lose their 
odor. The sputum is made up of the following: It 
is a thin fluid of a dirty green gray or brown color 
with more or less altered blood mixed with it. On 
standing, it separates, according to Traube, into 
three layers: the upper the foam, the middle clear, 
and the lower the sediment, made up of fat, fatty acid 
crystals, debris and fibres that show the arrange- 
ment of the alveoh. Elastic fibres are absent, due 



176 NOTES ON PHYSICAL DIAGNOSIS 

to the action of a ferment that destroys them 
(Filehne). If found it means that part of the lung 
tissue which has not undergone gangrene has been 
torn off. The smell of the breath is more apt to mis- 
lead one as there are so many conditions giving a 
foul breath. Other things are the bacterial fungus 
of Ditrich, the leptothrix of Leyden and Jaffe, the 
micrococcus of Hirschler and Terny; these have all 
been described as the specific cause of the gangrene. 
The chemical examination of the sputum shows fatty 
acids, ammonias, phenol, indol, skatol, etc. The 
general symptoms are those of fever, loss of strength 
and gastroenteric disturbances. Only the physical 
signs together with the sputum give an idea of the 
condition present. 

The physical signs are those of consolidation, soon 
followed (in a day or two) by signs of cavity. In 
the diffuse type the signs are more those of a rap- 
idly advancing infiltration, while in the local the 
cavity formation and the signs of such predominate. 
The differential diagnosis from putrid bronchitis and 
bronchiectasis may be difficult so long as the lung 
structure is absent from the sputum of gangrene. 
The physical signs are not so local or distinctive in 
the first two named conditions, besides it must be 
kept in mind that these conditions may cause gan- 
grene at any time. Only by observing the case and 
taking into consideration the etiological factors of 
gangrene such as pneumonia, septic or decomposed 
emboli, diabetes, etc., can a diagnosis be made. 

Note. — The odor of the sputum in BroncJdectasis (multiple 
abscesses), Abscess and Gafigrene is a striking characteristic. In 



DISEASES OF THE PLEURA AND LUNGS i77 

bronchiectasis tlie offensiveness is so great that the sufferer is a source of 
annoyance to himself as well as to those in the same room and some- 
times in a large ward. It is among the rare conditions in which the 
patient is conscious of an odor produced in his own body. As an 
example of the opposite of this may be mentioned the offensive breath, 
often causing great embarrassment to the sufferer, from post-nasal 
catarrh and defective teeth dui not noticeable to the patient himself . — 
Editor. 

Pulmonary Syphilis. 

Only a probable diagnosis can be made in the cases 
of undoubted syphilis that have a contracting process 
of the lung tissue with dyspnoea and signs of bron- 
chial stenosis due to gumma formation and diffuse 
interstitial pulmonitis. The absence of the tubercle 
bacilH and the arrest of the process on antisyphilitic 
treatment aid the diagnosis. 

Tumors of the Lung. 

The small mediary tumors are impossible to diag- 
nose. Primary cancer of the lung, if of miliary infil- 
tration variety, gives few signs. The large local 
ones give signs of consolidation. The diagnosis is to 
be made on obtaining tumor masses in the sputum 
or after puncture. 

Echinococcus cysts give signs of consolidation, and 
are to be diagnosed only after finding booklets in the 
sputum or after puncture. A cyst of the liver may 
extend to the lung. 

^Actinomycosis of the lung may cause fibrinous con- 
solidation or cavities. The diagnosis is to be made 
on obtaining the organism in the sputum or the pleu- 
ral fluid. (James Israel.) 

Note i. — Rupture of an amoebic abscess from the liver into the lung 
gives prune-juice colored sputum which contains the amoeba^ There are 

12 



1 78 NOTES ON PHYSICAL DIAGNOSIS 

not pulmonary signs but a history of dysentery, and the amoeba in the 
sputum is conclusive evidence. — Editor, 

Note 2. — Enlarged bronchial and peri-bronchial glands (mediasti- 
num) from tuberculosis and other infections together with tumors of the 
mediastinum constitute one of the most obscure conditions in the thorax. 
Tuberculosis especially may have its chief seat here and yet yield pul- 
monary symptoms, as haemoptysis, expectoration and cough without any 
signs. The sputum too may or may not contain tubercle bacilli. — 
Editor. 



AUG 25 1905. 



